Claims Filing Manual

laims Filing Manual May 2013

ontents laim Filing... 5 Procedures for laim Submission... 5 laim Mailing Instructions.... 5 equests for Adjustments.... 5 Administrative or Medical Necessity Appeals... 5 laim Filing Deadlines... 6 Deadline Exceptions... 6 efunds for laims Overpayments or Errors... 6 laim Form Field equirements.... 6 MS 1500 laim Form equired Fields.... 7 Paper MS 1500 Instructions and Examples of Supplemental Information in Item 24... 10 Paper MS 1500 National Drug odes (ND)... 10 Electronic (EDI) MS 1500 Instructions and Examples of Supplemental Information in Item 24... 10 EDI MS 1500 Other Instructions... 11 EDI MS 1500 National Drug odes (ND)... 11 orrected MS 1500 claims via EDI.... 11 equired Fields (UB-04 laim Forms).... 12 ND on UB-04... 16 Submission of POA Indicators for Primary and Secondary Diagnoses... 17 General POA equirements.... 17 POA Indicators are as follows, blanks are not acceptable:... 17 POA oding... 17 eporting POA on the UB-04 laim Form... 17 eporting POA in Electronic 837I Format... 17 All Patient efined Diagnosis elated Groups (AP-DG).... 18 Birth Weight... 19 ommon auses of laim Processing Delays, ejections or Denials.... 19 Electronic Data Interchange (EDI) for Medical and Hospital laims.... 22 Submitting secondary claims electronically... 22 Electronic laims Submission (EDI).... 23 Hardware/Software equirements... 23 ontracting with Emdeon and Other Electronic Vendors... 23 ontacting the EDI Technical Support Group... 23 Specific Data ecord equirements.... 23 Electronic laim Flow Description.... 24 Invalid Electronic laim ecord ejections/denials... 24 Plan Specific Electronic Edit equirements.... 24 Example of a Professional Electronic laim... 25 Example of an Institutional Electronic laim... 28 Exclusions.... 31 Exlcuded laim ategories.... 31 Excluded Provider ategories... 31 2 Select Health laims Filing Manual www.selecthealthofsc.com

ommon ejections.... 31 Invalid Electronic laim ecords ommon ejections from Emdeon... 31 Invalid Electronic laim ecords ommon ejections from the Plan (EDI Edits within the laim System)... 31 835 Electronic emittance Advice.... 32 Electronic Billing Inquiries.... 32 How to Minimize etrospective hart eview... 33 Why are retrospective chart reviews necessary?... 33 Tips for Accurate Diagnosis oding... 33 EOB Denial odes.... 35 Appendix - Supplemental Information.... 36 Ambulance laims.... 37 Procedure ode Destination Modifiers.... 37 Authorization equirements For Ambulance Services.... 37 Ambulance Services Not overed... 37 Ambulatory Surgery laims.... 38 Anesthesia laims.... 38 ertified egistered Nurse Anesthetists (NA)... 38 Modifiers... 38 Behavioral Health laims.... 38 Identifying Mental Health laims... 38 Provider Types... 39 Authorization equirements.... 39 o-pays... 39 Labs... 39 Outpatient Behavioral Health in the E... 39 Inpatient Behavioral Health DGs.... 39 H/FQH Behavioral Health claims... 39 Behavioral Health services covered by Medicaid fee-for-service.... 39 hiropractic laims.... 40 Authorizations... 40 laim Submission... 40 laims inquiries... 40 Eligibility and benefits inquiry... 40 Provider elations... 40 Durable Medical Equipment (DME) laims........................................................ 40 Billing equirements... 40 eimbursement Types.... 40 Authorization equirements.... 41 Modifiers... 41 Enteral Therapy... 41 Nebulizers... 41 Early, Periodic, Screening and Diagnostic Testing (EPSDT) laims.... 41 Billing Guidelines... 41 Immunizations... 41 Additional Billing Notes... 41 Home Health.... 42 ontents 3

Authorizations requirements.... 42 o-pays... 42 Same day visits... 42 Billable Procedure odes:... 42 Home Infusions and Injectable Drugs laims.... 43 Authorization requirements... 43 Family Planning codes... 43 Maternity laims.... 43 Authorization equirements.... 43 Ultrasounds... 43 17-P Injections... 43 Nurse Midwives................................................................................................ 43 oordination of Benefits and o-pays.... 43 Multiple Surgical eduction Payment Policy... 44 Nursing Home laims.... 45 Authorization equirements.... 45 laim submission guidelines.... 45 Physical, Occupational and Speech Therapy laims.... 45 enal Dialysis laims... 45 Authorization requirements... 45 Exhibits... 46 MS 1500 Form... 47 HNS Fax Inquiry Form.... 48 Institute for Health and ecovery Integrated (IH) Screening Tool (SBIT).... 49 Prenatal isk Assessment Form... 50 UB-04 Form... 51 Universal 17-P Authorization Form.... 52 4 Select Health laims Filing Manual www.selecthealthofsc.com

laim Filing Procedures for laim Submission Select Health of South arolina, Inc. s First hoice health plan, hereafter referred to as the plan, is required by state and federal regulations to capture specific data regarding services rendered to its members. The provider must adhere to all billing requirements to ensure timely processing of claims. In most cases, Select Health follows the Medicaid billing requirements. laims for billable services provided to plan members must be submitted by the provider who performed the services. laims filed with the plan are subject to the following procedures: Verification that all required fields are completed on the MS 1500 or UB-04 forms. Verification that all diagnosis and procedure codes are valid for the date of service. Verification of member eligibility for services under the plan during the time period in which services were provided. Verification that the services were provided by a participating provider or that the out of plan provider has received authorization to provide services to the eligible. Verification that an authorization has been given for services that require prior authorization by the plan. Verification of whether there is Medicare coverage or any other third party resources, and if so, verification the plan is the payer of last resort on all claims submitted to the plan. When required data elements are missing or are invalid, claims will be rejected by the plan for correction and resubmission. ejected claims are defined as claims with invalid or missing required data elements, such as the provider tax identification number or member ID number, that are returned to the provider or EDI* source without registration in the claim processing system. This applies to claims submitted on paper or electronically. ejected claims are not registered in the claim processing system and can be resubmitted as a new claim. laims originally rejected for missing or invalid data elements must be corrected and resubmitted within 180 calendar days from the date of service. Denied claims are registered in the claim processing system but do not meet requirements for payment under plan guidelines. They should be resubmitted as a corrected claim. This applies to claims submitted on paper or electronically. Denied claims must be resubmitted as corrected claims within 180 calendar days from the date of service. * For more information on EDI, review the section titled Electronic Data Interchange (EDI) for Medical and Hospital laims in this booklet. laim Mailing Instructions Submit claims to Select Health of South arolina, Inc. at the following address: Select Health of South arolina Attn: laim Processing Department P. O. Box 7120 London, KY 40742 The plan encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or Emdeon Provider Support Line at 1.800.845.6592 to arrange transmission. Note: Select Health Plan EDI Payer ID# 23285 Any additional questions may be directed to Provider laim Services at 1.800.575.0418 or to Select Health of South arolina s Network Operations department at 1.800.741.6605. equests for Adjustments equests for adjustments may be submitted by phone to: Provider laim Services at 1.800.575.0418 (Select the prompts for the correct plan and then select the prompt for claim issues.) If you prefer to write, please be sure to stamp each claim submitted corrected or resubmission and address the letter to: Select Health of South arolina Attn: laim Processing Department P. O. Box 7120 London, KY 40742 Administrative or Medical Necessity Appeals Administrative or medical necessity appeals must be submitted in writing to: Select Health of South arolina Attn: Appeals Department P. O. Box 40849 harleston, S 29423 laim Filing Procedures for laim Submission 5

Health care professionals submitting appeals on the behalf of a member must file the appeal within 90 calendar days of denial or action notification. efer to the Health are Professionals and Providers Manual online in the Provider section of the Select Health website at www.selecthealthofsc.com for complete instructions on submitting appeals. laim Filing Deadlines Original invoices must be submitted to the plan within 180 calendar days from the date services were rendered or compensable items were provided. esubmission of previously denied claims with corrections and requests for adjustments must be submitted within 365 days from the date services were rendered or compensable items were provided. Deadline Exceptions laims with Explanation of Benefits (EOBs) from primary insurers must be submitted within 60 days of the primary insurer s EOB. efunds for laims Overpayments or Errors The plan and South arolina Department of Health and Human Services (SDHHS) encourage providers to conduct regular self-audits to ensure accurate payment. Medicaid program funds that were improperly paid or overpaid must be returned. If the provider s practice determines it has received overpayments or improper payments, the provider is required to make immediate arrangements to return the funds to Select Health or follow the SDHHS protocol for returning improper payments or overpayment. 2. omplete the overpayment worksheet and submit along with a refund check for the overpayment/ improper payment amount directly to: Select Health of South arolina ost ontainment & TPL Department P O Box 7320 London, KY 40742 laim Form Field equirements The following charts describe the required fields that must be completed for the standard enters for Medicare and Medicaid Services (MS) MS 1500 or UB-04 claim forms. A sample of each form can be found in the exhibits. If the field is required without exception, an (required) is noted in the equired or onditional box. If completing the field is dependent upon certain circumstances, the requirement is listed as (conditional), and the relevant conditions are explained in the Instructions and omments box. The MS 1500 claim form must be completed for all professional medical services, and the UB-04 claim form must be completed for all facility claims. All claims must be submitted within the required filing deadline of one year from the date of service. Although the following examples of claim filing requirements refer to paper claim forms, claim data requirements apply to all claim submissions, regardless of the method of submission (electronic or paper). ontact Select Health Provider laim Services at 1.800.575.0418 to arrange the repayment. There are two ways to return overpayments: 1. omplete the overpayment worksheet located on the Select Health website, www.selecthealthofsc.com, in the Provider section under Provider Forms and have the plan deduct the overpayment/improper payment amount from future claims payments. Send the completed form to: Select Health of South arolina Attn: laims Processing Department P O Box 7120 London, KY 40742 6 Select Health laims Filing Manual www.selecthealthofsc.com

MS 1500 laim Form equired Fields MS 1500 laim Form equired Fields Field # Field Description Instructions and omments 1 INSUANE POGAM IDENTIFIATION heck only the type of health coverage applicable to the claim. This field indicates the payer to whom the claim is being filed. equired or onditional* 1a INSUED S ID NUMBE Health plan s member identification number or Medicaid identification number. 2 PATIENT S NAME (Last Name, First Name, Middle Initial) Enter the patient s name as it appears on the member s health plan I.D. card. 3 PATIENT S BITH DATE/SEX MMDDYY/M or F. 4 5 6 7 INSUED S NAME (Last Name, First Name, Middle Initial) PATIENT S ADDESS (Number, Street, ity, State, Zip ode) Telephone (include Area ode) PATIENT ELATIONSHIP TO INSUED INSUED S ADDESS (Number, Street, ity, State, Zip ode) Telephone (include Area ode) 8 PATIENT STATUS 9 9a 9b 9c 9d 10a, b, c OTHE INSUED S NAME (Last Name, First Name, Middle Initial) OTHE INSUED S POLIY O GOUP NUMBE OTHE INSUED S BITH DATE/ SEX EMPLOYE S NAME O SHOOL NAME INSUANE PLAN NAME O POGAM NAME IS PATIENT S ONDITION ELATED TO: Enter the patient s name as it appears on the member s health plan I.D. card. Enter the patient s complete address and telephone number. Do not punctuate the address or phone number. Always indicate self. Enter the patient s marital status. Indicate if the patient is employed or is a student. efers to someone other than the patient. ompletion of fields 9a through 9d is required if patient is covered by another insurance plan. Enter the complete name of the insured. EQUIED if #9 is completed. EQUIED if #9 is completed. MMDDYY/M or F by check box. This field is related to the insured in field #9. EQUIED if #9 is completed. Indicate yes or no for each category. Is condition related to employment, auto accident or other accident? 10d ESEVED FO LOAL USE Not equired 11 INSUED S POLIY GOUP O FEA NUMBE equired when other insurance is available. omplete if more than one other medical insurance is available or if yes to 10a, b, c. 11a INSUED S BITH DATE/SEX Same as #3. equired if 11 is completed. 11b 11c 11d 12 13 EMPLOYE S NAME O SHOOL NAME INSUANE PLAN NAME O POGAM NAME IS THEE ANOTHE HEALTH BENEFIT PLAN? PATIENT S O AUTHOIZED PESON S SIGNATUE INSUED S O AUTHOIZED PESON S SIGNATUE equired if employment is indicated in field #10. Enter name of health plan. equired if #11 is completed. Yes or no by check box. If yes, complete #9a-d. Enter Signature on File, SOF or legal signature. Enter Signature on File, SOF or legal signature. Not equired *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. laim Form Field equirements MS 1500 laim Form equired Fields 7

MS 1500 laim Form equired Fields Field # Field Description Instructions and omments 14 15 16 17 17a 17b 18 equired or onditional* DATE OF UENT: ILLNESS (First symptom) O INJUY (Accident) O PEGNANY (LMP) MMDDYY. IF PATIENT HAS SAME O SIMILA ILLNESS, GIVE FIST MMDDYY. DATE DATES PATIENT UNABLE TO WOK IN UENT OUPATION MMDDYY. NAME OF EFEING PHYSIIAN O OTHE SOUE OTHE I.D. NUMBE OF EFEING PHYSIIAN NATIONAL POVIDE IDENTIFIE (NPI) HOSPITALIZATION DATES ELATED TO UENT SEVIES equired if a provider other than the member s primary care physician referred, ordered or supervised the services or supplies on the claim. Enter the health plan provider number for the referring physician. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right of #17a. equired if #17 is completed. NU defines the following qualifiers used in 5010A1: 0B State License Number 1G Provider UPIN G2 Plan Assigned Provider ID LU Location Number (this qualifier is used for supervising provider only) Enter the NPI number of the referring provider, ordering provider or other source. equired if #17 is completed. equired when place of service is inpatient. MMDDYY. 19 ESEVED FO LOAL USE Not equired 20 OUTSIDE LAB HAGES Not equired 21 22 DIAGNOSIS O NATUE OF ILLNESS O INJUY. (elate items 1,2,3, O 4 to item 24E by line) MEDIAID ESUBMISSION ODE OIGINAL EF. NO. 23 PIO AUTHOIZATION NUMBE 24a DATE(S) OF SEVIE Diagnosis codes must be valid ID codes for the date of service. E codes are NOT acceptable as a primary diagnosis. NOTE: laims with invalid diagnosis codes will be denied for payment. Medicaid resubmission code: For electronic claims Use 6 for adjustment of prior claim. Use 7 for replacement of a prior claim in loop 2300 Original EF No: EF01 = F8 EF02 = 13 digit original claim number, no dashes or spaces For paper claims: For resubmissions or adjustments, enter ADJ in the esubmission ode section. Enter the claim ID# of the original claim in the Original ef No. section. Enter the authorization number. efer to the Provider Manual or call Provider Services to determine if services rendered require an authorization. If filing drug related codes, in the shaded area enter the ND qualifier followed by the ND number. ND qualifier: N4. For all claims, in the unshaded area, enter the from and to date in the MMDDYY format. If the service was performed on one day there is no need to complete the to date. 24b PLAE OF SEVIE Enter the MS standard place of service code. 24c EMG This field was originally titled type of service and is no longer used. This is now an emergency indicator field. Enter Y for yes or leave blank for no in the bottom unshaded area of the field. *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 8 Select Health laims Filing Manual www.selecthealthofsc.com

MS 1500 laim Form equired Fields Field # Field Description Instructions and omments 24d 24e 24f POEDUES, SEVIES O SUPPLIES PT/HPS MODIFIE DIAGNOSIS ODE HAGES For all claims in the unshaded area, enter procedure codes (5-7 digits) and modifiers (2 digits) must be valid for date of service. Note: Modifiers affecting reimbursement must be placed in the 1 st modifier position. Diagnosis Pointer - Indicate the associated diagnosis by referencing the pointers listed in field 21 (1, 2, 3, or 4). Diagnosis codes must be valid ID codes for the date of service. Enter charges. Enter zero ($0.00) or actual charged amount. A value must be entered including capitated services. equired or onditional* 24g DAYS O UNITS Enter quantity. Value must be greater than zero. (Field allows up to 3 digits.) 24h EPSDT FAMILY PLAN Not equired 24i 24j 25 ID QUALIFIE ENDEING POVIDE ID FEDEAL TAX ID NUMBE SSN/ EIN If the rendering provider does not have an NPI number, the qualifier indicating what the number represents is reported in the qualifier field in 24i. If the other ID number is the health plan ID number, enter G2. If the other ID number is another unique identifier, refer to the NU guidelines for the appropriate qualifier. The individual rendering the service is reported in 24j. Enter the health plan ID number in the shaded area of the field. emember to use qualifier G2. Enter the NPI number in the unshaded area of the field. Physician or supplier s federal tax ID (employer identification or Social Security) number. ecommended 26 PATIENT S AOUNT NO. The provider s billing account number. 27 AEPT ASSIGNMENT? Always indicate YES. efer to the back of the MS 1500 (08-05) form for the section pertaining to Medicaid payments. 28 TOTAL HAGE Enter the total billed amount for all services. 29 AMOUNT PAID EQUIED when another carrier is the primary payer. Enter the payment received from the primary payer prior to invoicing the plan. Medicaid programs are always the payers of last resort. 30 BALANE DUE EQUIED when #29 is completed. 31 32 33 SIGNATUE OF PHYSIIAN O SUPPLIE INLUDING DEGEES O EDENTIALS/DATE NAME AND ADDESS OF FAILITY WHEE SEVIES WEE ENDEED (If other than home) PHYSIIAN S, SUPPLIE S BILLING NAME, ADDESS, ZIP ODE AND PHONE NUMBE May use signature on file if the provider s billing designee has a written attestation signed by the provider that allows the billing designee to file claims on the provider s behalf. EQUIED unless #33 is the same information. Enter the physical location, with a 9-digit zip code, include the hyphen. (P.O. Box # s are not acceptable.) 32a Enter the NPI number (unless rendering provider is not required to have an NPI). 32b Enter the ID qualifier and the Medicaid ID number or taxonomy code. Qualifiers: Use 1D with Medicaid ID or ZZ with taxonomy code (no spaces). Enter the complete name and address of the provider requesting to be paid for services. Enter a street address; a P.O. Box is no longer allowed in this field. Do not use punctuation or use other symbols in the address, and enter a 9-digit zip code, including the hyphen. 33a Enter the NPI number (unless rendering provider is not required to have an NPI). 33b Enter the ID qualifier and the Medicaid ID number or taxonomy code. Qualifiers: Use 1D with Medicaid ID or ZZ with taxonomy code (no spaces). *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. laim Form Field equirements MS 1500 laim Form equired Fields 9

Paper MS 1500 Instructions and Examples of Supplemental Information in Item 24 The following are types of supplemental information that can be entered in the shaded lines of item number 24: Anesthesia duration in hours and/or minutes with start and end times Narrative description of unspecified codes National Drug odes (ND) for drugs (see next section for more information) Vendor Product Number Health Industry Business ommunications ouncil (HIB) Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN), formerly Universal Product ode (UP) for products Product ode (UP) for products formerly Universal ontract rate The following qualifiers are to be used when reporting these services. 7 Anesthesia information ZZ Narrative description of unspecified code (all miscellaneous fields require this section be reported) N4 National Drug odes VP Vendor Product Number Health Industry Business ommunications ouncil (HIB) OZ Product Number Health are Uniform ode ouncil Global Trade Item Number (GTIN) T ontract rate All unspecified procedure or HPS codes require a narrative description be reported in the shaded portion of field 24. The shaded area of lines 1 through 6 allow for the entry of 61 characters from the beginning of 24A to the end of 24G. To enter supplemental information, begin at 24A by entering the qualifier and then the information. Do not enter a space between the qualifier and the number/code/ information. Do not enter hyphens or spaces within the number/code. More than one supplemental item can be reported in the shaded lines of item number 24. Enter the first qualifier and number/code/information at 24A. After the first item, enter three blank spaces and then the next qualifier and number/code/information. Paper MS 1500 National Drug odes (ND) ND should be entered in the shaded sections of item 24A through 24G. To enter ND information, begin at 24A by entering the qualifier N4 and then the 11 digit ND information. Do not enter a space between the qualifier and the 11-digit ND number. Enter the 11-digit ND number in the 5-4-2 format (no hyphens). Do not use 99999999999 for a compound medication. Bill each drug as a separate line item with its appropriate ND. Enter the drug name and strength. Enter the ND quantity unit qualifier: F2 International Unit G Gram ML Milliliter UN Unit Enter the ND quantity. Do not use a space between the ND quantity unit qualifier and the ND quantity. Note: The ND quantity is frequently different than the HP code quantity. Example of entering the identifier N4 and the ND number on the MS 1500 claim form: 1 N4 qualifier 24. A. DATE(S) OF SEVIE B.. D. POEDUES, SEVIES, O SUPPLIES From To PLAE OF (Explain Unusual ircumstances) MM DD YY MM DD YY SEVIE EMG PT/HPS MODIFIE N400074202302 KETOLA 15MG/ML SYING 10 15 12 11 15 12 11 J1885 11-digit ND number Drug name and strength ND quantity ML2 ND unit qualifier Electronic (EDI) MS 1500 Instructions and Examples of Supplemental Information in Item 24 Details pertaining to EPSDT, anesthesia minutes and corrected claims may be sent in Notes (NTE) or emarks (NSF format). Details sent in NTE that will be included in claim processing: Please include L1, L2, etc. to show line numbers related to the details. Please include these letters after those specified below: EPSDT claims need to begin with the letters EPSDT followed by the specific code. Anesthesia minutes need to begin with the letters ANES followed by the specific times. orrected claims need to begin with the letters DIAGNOSIS 10 Select Health laims Filing Manual www.selecthealthofsc.com

P followed by the details of the original claim (as per contract instructions). DME claims requiring specific instructions should begin with DME followed by specific details. EDI MS 1500 Other Instructions EDI Field 33b (Professional) Field 33b Other ID# - Professional: 2310B loop, EF01=G2, EF02+ Plan s Provider Network Number. This field holds less than 13 Digits - Alphanumeric. Field is required. Note: Do not send the provider on the 2400 loop. This loop is not used in determining the provider ID on the claims. EDI Field 45 and 51 (Institutional) Field 45 Service Date must not be earlier than the claim statement date. Service Line Loop 2400, DTP*472. laim statement date Loop 2300, DTP*434. Field 51 Health Plan ID the number used by the health plan to identify itself. Select Health Plan EDI Payer ID# is 23285. EDI eporting DME DME claims requiring specific instructions should begin with DME followed by specific details. Example: NTE*ADD*DME AEOSOL MASK, USED W/DME NEBULIZE. EDI claims with ND information should be sent using the 2410 loop line segment. Please consult your EDI vendor if not submitting in X12 format for details on where to submit the ND number to meet this specification. orrected MS 1500 claims via EDI Use 6 for adjustment of prior claims or 7 for replacement of a prior claim utilizing bill type in loop 2300, LM05-03 (837P). Include the original claim number in segment EF01=F8 and EF02=the 13 digit original claim number; no dashes or spaces. Do include the plan s claim number to submit your claim with the 6 or 7. Do use this indicator for claims that were previously processed (approved or denied). Do not use this indicator for claims that contained errors and were not processed (rejected upfront). Do not submit corrected claims electronically and via paper at the same time. EDI MS 1500 National Drug odes (ND) The ND is used to report prescribed drugs and biologics when required by government regulation or as deemed by the provider to enhance claim reporting/adjudication processes. ontinue to report ND in the LIN segment of Loop ID-2410. This segment is used to specify billing/ reporting for drugs provided that may be part of the service(s) described in SV1. When LIN02 equals N4, LIN03 contains the ND number. This number should be sent with no hyphens and should be 11 digits. Submit one occurrence of the LIN segment per claim line. laims requiring multiple ND s sent at claim line level should be submitted using MS 1500 or UB-04 paper claim. When submitting ND in the LIN segment, the TP segment is requested. This segment is to be submitted with the unit of measure and the quantity. When submitting this segment, TP03 (pricing), TP04 (quantity) and TP05 (unit of measure) are required. laim Form Field equirements MS 1500 laim Form equired Fields 11

equired Fields (UB-04 laim Forms) UB-04 laim Form equired Fields Field # Field Description Instructions and omments 1 2 UNLABELED FIELD Provider name, address and telephone number UNLABELED FIELD Pay-To name, address and secondary ID fields Line a: complete provider name Line b: complete address or post office number Line c: city, state and zip code Line d: area code and telephone number Enter the emit address. Billing provider s designated pay-to address. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* 3a PATIENT ONTOL NO. Provider s patient account/control number. 3b MEDIAL EOD NO. Enter the patient s medial or health record number. Not required Not required 4 TYPE OF BILL 5 FED. TAX NO. 6 STATEMENT OVES PEIOD FOM/THOUGH Enter the appropriate three- or four-digit code. 1 st position indicates lead zero (do not include the lead zero on electronic claims). 2 nd position indicates type of facility. 3 rd position indicates type of care. 4 th position indicates billing sequence. Enter the number assigned by the federal government for tax reporting purposes. Enter dates for the full range of services being invoiced. (Format: MMDDYY) 7 UNLABELD FIELD No entry required. Not required Not required 8a 8b 9a-e PATIENT IDENTIFIE PATIENT NAME PATIENT ADDESS eport only if number is different from the patient s Medicaid ID in Field 60. Patient s last name, first name and middle initial as it appears on the health plan ID card. Use a comma or space to separate the last and first names. Titles: (Mr., Mrs., etc.) should not be reported in this field. Prefix: No space should be left after the prefix of a name (e.g. McKendrick). Hyphenated names: Both names should be capitalized and separated by a hyphen (no space). Suffix: A space should separate a last name and suffix. Newborn claims: If the baby has not been named, insert girl or boy in front of the mother s last name. Verify that the appropriate last name is recorded for the mother and baby. The mailing address of the patient: Street address ity State ZIP code ountry code (report if other than USA) 10 PATIENT DATE OF BITH The patient s birth date in MMDDYYYY format. 11 PATIENT S SEX ADMISSION 12-15 The sex of the patient recorded at admission, outpatient service of start of care. M male F female U unknown *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 12 Select Health laims Filing Manual www.selecthealthofsc.com

UB-04 laim Form equired Fields Field # Field Description Instructions and omments 12 ADMISSION/STAT OF AE DATE Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* The start date for this episode of care. For inpatient this is the actual admission date of the patient. (Format: MMDDYY) 13 ADMISSION HOU ode referring to the hour during which the patient was admitted for inpatient or outpatient care. 14 ADMISSION TYPE ode indicating the priority of this admission/visit. Not required 15 SOUE OF EFEAL FO ADMISSION O VISIT (S) 16 DISHAGE HOU (DH) 17 DISHAGE STATUS (STAT) 18-28 ONDITION ODES 29 AIDENT STATE 30 UNLABELED FIELD 31-34 35-36 37a-b OUENE ODES AND DATES 31-34 a-b OUENE SPAN ODES AND DATES 35-36a-b UNLABELED FIELD ode indicating the source of the referral for this admission or visit. ode indicating the discharge hour of the patient from inpatient care. A code indicating the disposition or discharge status of the patient at the end service for the period covered on this bill, as reported in Field 6. A code used to identify conditions or events relating to this bill that may affect processing. If more than one code applies, list in numerical order. When services reported on the claim are related to an auto accident, the two-digit state abbreviation where the accident occurred must be entered. Enter the code and associated date defining significant event relating to this bill. If only one code and date are used, they must be entered in Field 31a, b. If more than one code and date are used, they must be entered in Fields 31a, b through 34 a, b in alphanumeric sequence using the MMDDYY format. ode and the related dates that identify an event that relates to the payment of the claim. EQUIED for resubmissions or adjustments. Enter the claim number of the original claim. Not required 38 UNLABELED FIELD esponsible party name and address. 39-41 VALUE ODES 39-41 a-d 42 EV.D. 43 DESIPTION 44 HPS/ATES/HIPPS ODE 45 SEV. DATE ode structure to relate amounts or values to identify data elements necessary to process this claim by the payer. If more than one value code applies, list in alphanumeric order. eporting birth weight - If reporting abnormal birth weight through use of Value odes, populate fields 39, 40, 41 a, b, c, d Value odes and Amounts. Use Value ode 54 and report the birth weight in grams. evenue ode odes that identify specific accommodations, services and items furnished to the patient in your facility. evenue code narrative description of the related revenue categories. Abbreviations may be used. Enter the applicable rate, PT, HPS or HIPPS code and modifier based on the bill type of inpatient or outpatient. eport line item dates of service for each revenue code or PT, HPS/HIPPS code. *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. laim Form Field equirements equired Fields (UB-04 laim Forms) 13

UB-04 laim Form equired Fields Field # Field Description Instructions and omments 46 SEV. UNITS eport units of service to include items such as number of accommodation days, miles, pints of blood, renal dialysis days, etc. Observations - eport OBS as one unit per 24 hour period up to 72 hours. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* 47 TOTAL HAGES eport grand total of submitted charges. 48 NON-OVEED HAGES To reflect the non-covered charges for the destination payer as it pertains to the related revenue code. equired when Medicare is primary. 49 UNLABELED FIELD Not equired Not equired 50 PAYE NAME 51 HEALTH PLAN ID 52 EL. INFO Enter the name for each payer being invoiced. When the patient has other coverage, list the payers as indicated below. Line A refers to the primary payer, B is secondary and is tertiary. The number used by the health plan to identify itself. Select Health s payer ID is 23285. elease of information certification indicator. This field is required on paper and electronic invoices. Line A refers to the primary payer, B to the secondary and to the tertiary. It is expected the provider has all necessary release information on file. It is expected all released invoices contain Y. 53 ASG. BEN. Valid entries are Y (yes) and N (no). 54 PIO PAYMENTS The A, B, indicators refer to the information in Field 50. 55 EST. AMOUNT DUE 56 57a-c NATIONAL POVIDE IDENTIFIE BILLING POVIDE OTHE (BILLING) POVIDE IDENTIFIE 58 INSUED S NAME 59 P. EL 60 INSUED S UNIQUE IDENTIFIE 61 GOUP NAME 62 INSUANE GOUP NO. 63 TEATMENT AUTHOIZATION ODES Enter the estimated amount due (the difference between total charges and any deductions such as other coverage). The unique identification number assigned to the provider submitting the bill. NPI is the National Provider Identifier. A unique identification number assigned to the provider submitting the bill by the health plan. eport the facility ID number assigned by the health plan. Information refers to the payers listed in Field 50. In most cases, this will be the patient name. When other coverage is available, the insured is indicated here. Enter the patient s relationship to insured. For Medicaid programs, the patient is the insured. (ode 01: Patient is insured). Enter the patient s health plan ID exactly as it appears on the patient s ID card on the same lettered line (a, b or c) that corresponds to the line on which the Select Health payer information was shown in Fields 50-51. When other insurance is present, enter that plan ID on line A. Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer, B to secondary and to tertiary. Use this field only when a patient has other insurance and group coverage applies. Do not use this field for individual coverage. Line A refers to the primary payer, B to secondary and to tertiary. Enter the health plan referral or authorization number. Line A refers to the primary payer, B to secondary and to tertiary. *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 14 Select Health laims Filing Manual www.selecthealthofsc.com

UB-04 laim Form equired Fields Field # Field Description Instructions and omments 64 DN 65 EMPLOYE NAME 66 67 67a-q DIAGNOSIS AND POEDUE ODE QUALIFIE PINIPAL DIAGNOSIS ODE and PESENT ON ADMISSION INDIATO (POA) Other Diagnosis odes 68 UNLABELD FIELD 69 ADMITTING DIAGNOSIS ODE 70 PATIENT S EASON FO VISIT 71 72a-c POSPETIVE PAYMENT SYSTEM (PPS) ODE EXTENAL AUSE OF INJUY (EI) ODE 73 UNLABELD FIELD Document ontrol Number - New field. The control number (claim number) assigned to the original bill by the health plan as part of their internal control. Previously, 64 contained the Employment Status ode (ES). The ES field has been eliminated. Note: esubmitted claims must contain the original claim ID. The name of the employer that provides health care coverage for the insured individual identified in Field 58. equired when the employer if the insured is known to potentially be involved in paying this claim. Line A refers to the primary payer, B to secondary and to tertiary. The qualifier that denotes the version of International lassification of Diseases (ID) reported. Qualifier codes: ID: 9 Ninth revision, 0 Tenth revision. Enter the complete ID diagnosis code; the condition established after study to be chiefly responsible for causing the admission of the patient for care. Include the 4th and 5th digits if applicable. Each diagnosis code must be valid for the date of service. Present on Admission is defined as present at the time the order for inpatient admission occurs. onditions that develop during an outpatient encounter, including emergency department, are considered as present on admission. The POA Indicator is applied to the principal diagnosis as well as all secondary diagnoses that are reported. The ID diagnoses codes corresponding to all conditions that coexist at the time of admission, develop subsequently or affect the treatment received and/or the length of stay. Exclude diagnoses that relate to an earlier episode, which have no bearing on the current hospital stay. Enter the complete ID diagnosis code, include the 4th and 5th digits if applicable, which describe the patient s diagnosis at admission. Enter the complete ID diagnosis code describing the patient s reason for visit at the time of outpatient registration. Include the 4th and 5th digits if applicable. equired for all unscheduled outpatient visits. Up to three ID codes may be entered in Fields a, b, c. The PPS codes assigned to the claim to identify the DG based on the grouper software called for under contract with the primary payer. equired when the health plan/provider contract requires this information. Up to four digits. The ID diagnosis codes pertaining to external cause of injuries, poisoning or adverse effect. External cause of injury E diagnosis codes should not be billed as primary and/or admitting diagnosis. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* Not required equired or onditional* Not required *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. laim Form Field equirements equired Fields (UB-04 laim Forms) 15

UB-04 laim Form equired Fields Field # Field Description Instructions and omments 74 74a-e PINIPAL POEDUE ODE AND DATE OTHE POEDUE ODES AND DATES 75 UNLABELD FIELD 76 77 78-79 ATTENDING POVIDE NAME AND IDENTIFIES NPI#/QUALIFIE/OTHE ID# OPEATING PHYSIIAN NAME AND IDENTIFIES NPI#/QUALIFIE/OTHE ID# OTHE POVIDE (INDIVIDUAL) NAMES AND IDENTIFIES NPI#/QUALIFIE/OTHE ID# 80 EMAKS FIELD 81 a-d TAXONOMY ODE The ID code that identifies the principal procedure performed at the claim level during the period covered by this bill and the corresponding date. Inpatient facility ID is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID is required when a surgical procedure is performed. The ID codes identifying all significant procedures other than the principal procedure and the dates (identified by code) on which the procedures were performed. Inpatient facility ID is required when a surgical procedure is performed. Outpatient facility or Ambulatory Surgical enter PT, HPS or ID is required when a surgical procedure is performed. Enter the NPI of the physician who has primary responsibility for the patient s medical care or treatment in the upper line and their name in the lower line, last name first. If the attending physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Enter the last name and first name of the attending physician. Enter the NPI of the physician who performed surgery on the patient in the upper line and their name in the lower line, last name first. If the operating physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Enter the last name and first name of the attending physician. equired when a surgical procedure code is listed. Enter the NPI# of any physician, other than the attending physician, who has responsibility for the patient s medical care or treatment in the upper line and his/her name in the lower line, last name first. If the other physician has another unique ID#, enter the appropriate descriptive two-digit qualifier followed by the other ID#. Area to capture additional information necessary to adjudicate the claim. If an NPI number is entered in Field 56 and the provider s NPI number is mapped to a taxonomy code, enter qualifying code B3 for Taxonomy code and enter the 10-digit Taxonomy code for the rendering provider. Inpatient, Bill Types Outpatient, Bill Types 11X, 12X, 21X, 22X, 32X 13X, 23X, 33X, 83X equired or onditional* equired or onditional* *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. ND on UB-04 ND should be entered in Form Locator 43 in the evenue Description Field. eport the N4 qualifier in the first two positions, left-justified. Do not enter spaces. Enter the 11-character ND number in the 5-4-2 format (no hyphens). 16 Select Health laims Filing Manual www.selecthealthofsc.com

Do not use 99999999999 for a compound medication. Bill each drug as a separate line item with its appropriate ND. Immediately following the last digit of the ND (no delimiter), enter the Unit of Measurement Qualifier. F2 International Unit G Gram ML Milliliter UN Unit Immediately following the Unit of Measure Qualifier, enter the unit quantity with a floating decimal for fractional units limited to three digits (to the right of the decimal). Any unused spaces for the quantity are left blank. Note that the decision to make all data elements leftjustified was made to accommodate the largest quantity possible. The description field on the UB-04 is 24 characters in length. An example of the methodology is illustrated below: N 4 1 2 3 4 5 6 7 8 9 0 1 U N 1 2 4 5. 5 6 7 Submission of POA Indicators for Primary and Secondary Diagnoses General POA equirements POA Indicator reporting is mandatory for all claims involving inpatient admissions to general acute care hospitals or other facilities. POA is defined as present at the time the order for inpatient admission occurs. onditions that develop during an outpatient encounter, including emergency department, observation or outpatient surgery, are considered POA. A POA Indicator must be assigned to principal and secondary diagnoses (as defined in Section II of the Official Guidelines for oding and eporting) and the external cause of injury codes. MS does not require a POA Indicator for an external cause of injury code unless it is being reported as an other diagnosis. Issues related to inconsistent, missing, conflicting or unclear documentation must be resolved by the provider. If a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current official coding guidelines, the POA Indicator would not be reported. POA Indicators are as follows, blanks are not acceptable: Y = Yes = present at the time of inpatient admission. N = No = not present at the time of inpatient admission. U = Unknown = documentation is insufficient to determine if condition was present at time of inpatient admission. W = linically Undetermined = provider is unable to clinically determine whether condition was present at time of inpatient admission or not. 1 = Exempt from POA reporting. POA oding Use the UB-04 Data Specifications Manual and the ID Official Guidelines for oding and eporting to facilitate the assignment of the POA indicator for each principal diagnosis and other ID diagnosis codes reported on the UB-04 and AS X12N 837 Institutional (837I). Hospitals reporting with the 5010 format will no longer report a POA Indicator of 1 for POA exempt codes. The POA field will instead be left blank for codes exempt from POA reporting. eporting POA on the UB-04 laim Form Fields 67 A Q: valid primary and secondary diagnosis codes (up to five digits) are to be placed in the unshaded portion of 67 A Q, followed by the applicable POA Indicator (one character) in the shaded portion of 67 A Q. Sample UB-04 populated with primary and secondary diagnosis codes and POA indicators: FL 67 Primary Diagnosis ode DX 2449 Y 25001A N 29620B U V1581 W D I J K L M 69 ADMIT 70 PATIENT DX EASON DX a b c 66 67 FL 67 POA FL 67 A-Q Secondary Diagnosis odes FL 67 A-Q POA 71 PPS ODE eporting POA in Electronic 837I Format The provider is to submit their POA data via the K3 segment on all 837I claims, (004010X096A1). Although this segment can repeat, the plan requires the provider to submit POA data on a single K3 segment. No additional K3 segments with the letters POA will be laim Form Field equirements Submission of POA Indicators for Primary and Secondary Diagnoses 17

validated. K301 must contain POA as the first three characters or the POA data will not be picked up. K3*POA~ K3 segment must only contain details pertaining to the Principal and Other Diagnosis found in the HI segment with qualifiers BK for Principal and BF for Other Diagnosis prior to the ending Z (or X). The POA Indicator for the BN External ause of Injury on the K3 segment with POA is entered following the ending Z (or X). This is required by Emdeon for Medicare claims as well. No POA Indicator is to be sent for the BJ/ZZ Admitting Diagnosis Data. Following the letters POA in the K3 segment is to be only those identified on the Medicare Bulletin. 1, Y, N, U, W are valid, with ending characters of X or Z and E-ode indicator. POA Indicator Example: POA Indicators for an electronic claim with one principal and five secondary diagnoses should be coded as: K3* POAYNUW1YZ.POA The principal diagnosis is always the first indicator after Y POA. In this example, the principal diagnosis was present on admission. The first secondary diagnosis was not present on admission, N designated by N. U W 1 Y Z It was unknown if the second secondary diagnosis was present on admission, designated by U. It is clinically undetermined if the third secondary diagnosis was present on admission, designated by W. The fourth secondary diagnosis was exempt from reporting for POA, designated by 1. NOTE: Hospitals reporting with the 5010 format on and after Jan. 1, 2011, will no longer report a POA indicator of 1 for POA exempt codes. The POA field will instead be left blank for codes exempt from POA reporting. The fifth secondary diagnosis was present on admission, designated by Y. The last secondary diagnosis indicator is followed by the letter Z to indicate the end. The next table outlines the payment implications for each of the different POA Indicators. MS POA Indicator Options and Definitions ode eason for ode Y N U W 1 Diagnosis was present at time of inpatient admission. MS will pay the complicating condition/major complicating condition (/M) DG for those selected Hospital Acquired onditions (HAs) that are coded as Y for the POA Indicator. Diagnosis was not present at time of inpatient admission. MS will not pay the /M DG for those selected HAs that are coded as N for the POA Indicator. Documentation insufficient to determine if the condition was present at the time of inpatient admission. MS will not pay the /M DG for those selected HAs that are coded as U for the POA. linically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission. MS will pay the /M DG for those selected HAs that are coded as W for the POA Indicator. Unreported/Not used. Exempt from POA reporting. This code is equivalent to a blank on the UB-04, however; it was determined that blanks are undesirable when submitting this data via the 4010A. MS will not pay the /M DG for those selected HAs that are coded as 1 for the POA Indicator. The 1 POA Indicator should not be applied to any codes on the HA list. Key Points: IPPS hospitals will no longer report the POA Indicator of 1. ID-M diagnosis codes that are exempt from the POA reporting requirement should be left blank instead of populating a 1. In addition, the K3 segment, which was required for reporting POA in the 4010A1 version of the 837I, is no longer used to report POA. For 5010 the POA indicators will instead follow the diagnosis code in the appropriate 2300 HI segment. All Patient efined Diagnosis elated Groups (AP-DG) Effective with dates of service Jan. 1, 2012, Select Health moved to the All Patient efined Diagnosis elated Groups (AP-DGs) method of paying for hospital inpatient services. The goals of the AP-DGs payment are to employ a methodology that is sustainable and more appropriate to Medicaid using a modern DG algorithm, which enables reduced payment for hospital-acquired conditions and simplifies the current payment method. 18 Select Health laims Filing Manual www.selecthealthofsc.com

AP-DGs version 28 replaced the current 3M grouper version 24. AP-DGs is a classification system that classifies patients according to: eason for admission. Severity of illness (SOI). AP-DGs grouping process: SOI is used for payment calculation. Dependent on patient diagnosis and procedures. Severity levels define the degree of illness a patient is experiencing. Payment is adjusted to appropriately reimburse hospitals at a higher level for treating sicker patients. This payment method will apply to general acute care hospitals (including distinct-part units of general hospitals both inside South arolina and out of state. Payment methods for inpatient services provided by free-standing long-term psychiatric facilities and residential treatment facilities are unaffected. Birth Weight With the implementation of the AP-DGs payment methodology, Select Health must ensure we are reporting the appropriate encounter data for abnormal birth weights; therefore, we are requesting providers bill as follows: Please use ID M code ranges V21.30-V21.35 or 764 765.1 as appropriate and/or Birth weight can be reported through use of Value ode 54 followed by the actual birth weight in grams Birth weight must be numeric. Birth weight must be a whole number without decimal points. Birth weight cannot be greater than four numeric characters (9999). Birth Weight Billing Examples UB-04 Paper claim If reporting abnormal birth weight through the use of the applicable ID code, populate field 67. DX 764.08 A B D I J K L M 69 ADMIT 70 PATIENT DX EASON DX a b c 66 67 71 PPS ODE If reporting abnormal birth weight through use of value codes, populate fields 39, 40, 41 a, b, c, d value codes and Amounts. Use value code 54 newborn birth weight in grams. a b c d 39 VALUE ODES 40 VALUE ODES 41 VALUE ODES ODE AMOUNT ODE AMOUNT ODE AMOUNT 54 2134 Electronic Billing If billing electronically in addition to reporting the diagnosis code, please report abnormal birth weight in loop 2300, segment HI, with the qualifier BE and value code 54 in HI01-2 and the newborn s weight in grams in the monetary amount field - HI01-5. ommon auses of laim Processing Delays, ejections or Denials Authorizations or eferral Number Invalid or Missing A valid authorization number must be included on the claim form for all services requiring prior authorization. Attending Physician ID Missing or Invalid Inpatient claims must include the name of the physician who has primary responsibility for the patient s care or treatment and the medical license number in the appropriate field (76) on the UB-04 claim form. Medical license number formats are: 2 alpha, 6 numeric, 1 alpha (AANNNNNNA) or 2 alpha, 6 numeric characters (AANNNNNN). Billed harges Missing or Incomplete A billed charge amount must be included for each service/procedure/ supply on the claim form. Diagnosis ode Missing 4th or 5th Digit Precise coding sequences must be used to accurately complete processing. eview the ID-M manual for the fourth- and fifth-digit extensions. The Ö4th or Ö5th symbol in the manual determines when additional digits are required. Diagnosis, Procedure or Modifier odes Invalid or Missing oding From the most current coding manuals (ID-M, PT or HPS) or appropriate unique coding is required to accurately complete processing. All applicable diagnosis, procedure and modifier fields must be completed. DG odes Missing or Invalid Hospitals contracted for payment based on DG codes should include this information on the claim form. EOBs (Explanation of Benefits) from Primary Insurers laim Form Field equirements ommon auses of laim Processing Delays, ejections or Denials 19

Missing or Incomplete A copy of the EOB from all thirdparty insurers must be submitted with the original claim form. Include pages with run dates, coding explanations and messages. EPSDT Information Missing or Incomplete EPSDT information should be billed in accordance with the South arolina Medicaid Physician Provider Manual. Immunization administration, topical fluoride varnish, laboratory tests, blood level assessments, age limited screenings and elective tests are covered separately utilizing the appropriate PT code and billed according to the periodicity schedule. EPSDT services may be submitted electronically or on paper. The administration PT codes 90471 90474 are covered for the administration of vaccines provided through the VF program for beneficiaries age 19 and older. For the administration of vaccines by injection, the following PT codes must be used: 90471 Immunization administration This code will only cover the first vaccine administered. 90472 Each additional vaccine List separately in addition to code for primary procedure. Note: Use code 90472 in conjunction with code 90471. This code can only be billed twice per visit, regardless of how many additional vaccines are administered at the time of the visit. For the administration of the FluMIST or PV by intranasal or oral, the following PT codes must be used: 90473 Immunization administrations by intranasal or oral, one vaccine. This code will only cover the first vaccine administered per visit. 90474 Each additional intranasal or oral vaccine. For members under 19 years of age, you must use the new administration codes: 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component (one unit per date of service). 90461 Each additional vaccine/toxoid component (two units per date of service). PT advises to bill these codes based on the number of components. At this time, SDHHS will continue to use these codes per admin istration of each vaccine/toxoid and not per compo nent for the VF program. The administration of VF vaccines is limited to a maximum of three units per date of service regard less of the number of additional vaccines adminis tered. Include all primary and secondary diagnosis codes on the claim. Missing or invalid data elements or incomplete claim forms will cause claim-processing delays, inaccurate payments, rejections or denials. egardless of whether reimbursement is expected, the billed amount of the service must be documented on the claim. Missing charges will result in rejections or denials. All billed codes must be complete and valid for the time period in which the service is rendered. Incomplete, discontinued or invalid code will result in claim rejections or denials. State-level HPS coding takes precedence over national level codes unless otherwise specified in individual provider contracts. The services billed on the claim form should exactly match the services and charges detailed on the accompanying EOB. If the EOB charges appear different due to global coding requirements of the primary insurer, submit claim with the appropriate coding, which matches the total charges on the EOB. Secondary claims can also be submitted electronically. efer to the section entitled Submitting Secondary laims Electronically. EPSDT oding Tips Modifiers 01 and 02 are not required for EPSDT claim submission to First hoice. Primary care physicians can bill for topical fluoride varnish treatments, PT code D1206 as part of the EPSDT exam. laims for VF vaccine administration must include: The appropriate vaccination product (toxoid) PT code. The appropriate vaccination administration code for this code combination, only the adminis tration code will be reimbursable. When billing First hoice, Federally Qualified Health enters (FQHs) and ural Health enters (Hs) must also submit PT codes for the vaccination products. When billing for vaccines not covered under the VF program or for beneficiaries over the age of 19, the provider may bill for the vaccine and the administration code 96372. 20 Select Health laims Filing Manual www.selecthealthofsc.com

If you detect a health problem during a well visit, do not change the coding from a well exam to a sick visit. When billing, use V20.2 as the first diagnosis. The second diagnosis is determined by the detected problem. If the EPSDT screening and immunizations can be completed, bill the EPSDT code with modifier 25 and list any additional services. Modifier 25 is required on E&M services billed on the same date as vaccine services. Do NOT bill an office visit on the same date of service. All required elements of the EPSDT visit (a blood pressure check, hearing screening, etc.) are included in your reimbursement rate and should not be billed separately. Any sports physical may qualify as an EPSDT screening as long as all components are included in the exam. External ause If Injury odes External auses of Injury, E diagnosis codes, should not be billed as primary and/or admitting diagnosis. Future laim Dates laims submitted for medical supplies or services with future claim dates will be denied. For example, a claim submitted on Oct. 1 for bandages that are delivered for Oct. 1 through Oct. 31, will deny for all days except Oct. 1. Handwritten laims See Illegible laim Information Highlighted laim Fields See Illegible laim Information Illegible laim Information Information on the claim form must be legible to avoid delays or inaccuracies in processing. eview billing processes to ensure forms are typed or printed in black ink, that no fields are highlighted (this causes information to darken when scanned or filmed) and spacing and alignment are appropriate. Handwritten information often causes delays or inaccuracies due to reduced clarity. Submitting the original copy of the claim form will assist in assuring claim information is legible. Incomplete Forms All required information must be included on the claim forms to ensure prompt and accurate processing. Member Name Missing The name of the member must be present on the claim form and must match the information on file with the plan. Member Medicaid or Health Plan ID Number Missing or Invalid The Medicaid or health plan s assigned member ID must be included on the claim form or electronic claim submitted for payment. Member Date of Birth does not match Member ID Submitted laims submitted with the incorrect date of birth will be rejected on the front end. The date of birth must be present on the claim form and must match the information on file with the plan. Newborn laim Information Missing or Invalid Newborns must be billed separately from the mother. If the baby has not been named, insert Girl or Boy in front of the mother s last name as the baby s first name. Verify that the appropriate last name is recorded for the mother and baby. The claim for baby must include the baby s date of birth and Medicaid number. Please do not use the mother s DOB or Medicaid number. On claims for twins or other multiple births, indicate the birth order in the patient name field For example: Baby Girl Smith A, Baby Girl Smith B, etc. Payer or Other Insurer Information Missing or Incomplete Include the name, address and policy number for all insurers covering the plan member. Place of Service ode Missing or Invalid A valid and appropriate two-digit numeric code must be included on the claim form. efer to MS 1500 coding manuals for a complete list of place of service codes. Any changes in a participating provider s name, address or tax identification number(s) must be reported to the plan immediately. ontact your Provider Account Executive to assist in updating the plan s records, or call Provider Services at 1.800.741.6605. Provider Name Missing The name of the provider of service must be present on the claim form and must match the service provider name and TIN on file with the plan. The individual service provider name and NPI number must be indicated on all claims, excluding, ambulance service providers, DME and home health agencies and laboratories. Using only the group or billing entity name and number will result in rejections, denials or inaccurate payments. Provider NPI Number Missing or Invalid The individual and group NPI numbers for the service provider must be included on the claim form. When the provider or facility has more than one NPI number, use the NPI number that matches the laim Form Field equirements ommon auses of laim Processing Delays, ejections or Denials 21

services submitted on the claim form. Imprecise use of NPI numbers results in inaccurate payments or denials. evenue odes Missing or Invalid Facility claims must include a valid three- or four-digit numeric revenue code. efer to UB-04 coding manuals for a complete list of revenue codes. Signature Missing The signature of the provider of service or signature on file should be present on the claim form and must match the service provider name and TIN on file with the plan. This does not apply to provider types ambulance, DME, home health, lab, hospital or DHE). laims without the provider signature or signature on file in box 31 will be rejected. The provider is responsible for resubmitting these claims within one year from the date of service. Spanning Dates of Service Do Not Match the Listed Days/ Units Span-dating is only allowed for identical services provided on consecutive dates of service. Always enter the corresponding number of consecutive days in the days/ unit field. Tax Identification Number (TIN) Missing or Invalid The Tax ID number must be present and must match the service provider name and payment entity (vendor) on file with the plan. laims without tax identification (TIN) will be rejected. The provider is responsible for resubmitting these claims within one year from the date of service. Third-Party Liability (TPL) Information Missing or Incomplete Any information indicating a work-related illness/injury, no fault or other liability condition must be included on the claim form. Additionally, a copy of the primary insurer s Explanation of Benefits (EOB) or applicable documentation must be forwarded along with the claim form. Type of Bill A code indicating the specific type of bill (e.g., hospital, inpatient, outpatient, replacements, voids, etc.). The first digit is a leading zero. Do not include the leading zero on electronic claims. Do not attach notes to the face of the claim. This will obscure information on the claim form or may become separated from the claim prior to processing. Do not highlight any information on the claim form or accompanying documentation. Highlighted information will become illegible when scanned or filmed. Electronic Data Interchange (EDI) for Medical and Hospital laims Electronic Data Interchange (EDI) allows faster, more efficient and cost-effective claim submission for providers. EDI, performed in accordance with nationally recognized standards, supports the health care industry s efforts to reduce administrative costs. The benefits of billing electronically include: eduction of overhead and administrative costs. EDI eliminates the need for paper claim submission. It has also been proven to reduce claim rework (adjustments). eceipt of clearinghouse reports makes it easier to track the status of claims. Faster transaction time for claims submitted electronically. An EDI claim averages about 24 to 48 hours from the time it is sent to the time it is received. This enables providers to easily track their claims. Validation of data elements on the claim form. By the time a claim is successfully received electronically, information needed for processing is present. This reduces the chance of data entry errors that occur when completing paper claim forms. Quicker claim completion. laims that do not need additional investigation are generally processed quicker. eports have shown that a large percentage of EDI claims are processed within 10 to 15 days of their receipt. ALL THE SAME EQUIEMENTS FO PAPE LAIM FILING APPLY TO ELETONI LAIM FILING. Please allow for normal processing time before resubmitting the claim through EDI or paper claim. This will reduce the possibility of your claim being rejected as a duplicate claim. To verify satisfactory receipt and acceptance of submitted records, please review both the Emdeon Acceptance report and the 059 Plan Acceptance eport (laim Status eport). EFE TO the laim Filing section for general claim submission guidelines. Submitting secondary claims electronically The required OB data elements for submitting Electronic Data Interchange (EDI) claims to Select Health may be 22 Select Health laims Filing Manual www.selecthealthofsc.com

gathered from the previous payer s adjudi cation, in both paper and electronic (835) remittance advice formats. To submit provider-to-payer coordination of benefits (OB) claims via EDI, you must have a system, data entry process or clearinghouse able to: 1. reate or forward claims directly to EDI in: the HIPAA 837 format; or format containing equivalent information AND 2. Process payment information by: eceiving a HIPAA-standard electronic remittance advice (EA) format from the previous payer or oding a paper remittance into the electronic claim. Select Health s OB data requirements align with HIPAA guidelines. The 837 Implementation Guide may be found online at: www.scdhhs.gov/resource/sc-medicaid-companion-guides Electronic laims Submission (EDI) If you are a provider who already has electronic filing capabilities, you should contact your vendor and confirm the vendor will transmit claims to Emdeon, Select Health s claims clearinghouse. Providers should confirm with the vendor the accurate location of Select Health provider ID number. If viewing a MS 1500 Individual provider ID number should be submitted in box 24j, shaded area. If viewing a UB-04, the ID number should be submitted in box 51. HOSPITAL O FAILITY PLEASE USE FAILITY ID NUMBE ASSIGNED BY SELET HEALTH. Submit with Payer ID 23285. Provider should check the claims status report after each submission for any rejections. If rejections are noted, correct and resubmit. Questions regarding electronically submitted claims should be directed to Provider laim Services at 1.800.575.0418. Here you may obtain information about submitting claims electronically to Select Health or information regarding claims that have already been submitted electronically to Select Health. The following sections describe the procedures for electronic submission for hospital and medical claims. Included are a high-level description of claims and report process flows, information on unique electronic billing requirements and various electronic submission exclusions. Hardware/Software equirements There are many different products that can be used to bill electronically. As long as you have the capability to send EDI claims to Emdeon, whether through direct submission or through another clearinghouse/vendor, you can submit claims electronically. ontracting with Emdeon and Other Electronic Vendors If you are a provider interested in submitting claims electronically to the plan but do not currently have Emdeon EDI capabilities, you can contact Emdeon Sales at 1.800.845.6592. You may also choose to contract with another EDI clearinghouse or vendor who already has Emdeon capabilities. Emdeon is the largest clearinghouse for EDI health care transactions in the world. It has the capability to accept electronic data from numerous providers in several standardized EDI formats and then forwards accepted information to carriers in an agreed upon format. Providers using Emdeon or other clearinghouses and vendors are responsible for arranging to have rejection reports forwarded to the appropriate billing or open receivable departments. ontacting the EDI Technical Support Group Providers interested in sending claims electronically may contact the EDI Technical Support Group for information and assistance in beginning electronic submissions. When ready to proceed: ead over the instructions within this booklet carefully with special attention to the information on exclusions, limitations and especially, the rejection notification reports. ontact your EDI software vendor and/or Emdeon to inform them you wish to initiate electronic submissions to the plan. Be prepared to inform the vendor of the plan s electronic payer identification number. The payer ID for Select Health is 23285. ontact EDI Technical Support at 1.800.575.0418 or by email at edi.sh@kmhp.com. Specific Data ecord equirements laims transmitted electronically must contain all the same data elements identified within the laim Filing section of this booklet. Emdeon or any other EDI clearinghouse or Electronic Data Interchange (EDI) for Medical and Hospital laims Electronic laims Submission (EDI) 23

vendor may require additional data record requirements. Electronic laim Flow Description To send claims electronically to the plan, all EDI claims must first be forwarded to Emdeon. This can be completed via a direct submission or through another EDI clearinghouse or vendor. Once Emdeon receives the transmitted claims, they are validated against Emdeon s proprietary specifications, HIPPA compliance and plan-specific requirements. laims not meeting the requirements are immediately rejected and sent back to the sender via an Emdeon error report. The name of this report can vary based upon the provider s contract with their intermediate EDI vendor or Emdeon. Accepted claims are passed to the plan, and Emdeon returns an acceptance report to the sender immediately. laims forwarded to the plan by Emdeon are validated against provider and member eligibility records. laims that do not meet this requirement are rejected and sent back to Emdeon daily, which also forwards this rejection to its trading partner the intermediate EDI vendor or provider. laims passing eligibility requirements are then passed to the claim processing queues. laims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data. laims are not considered as received under timely filing guidelines if rejected for missing or invalid provider or member data. Providers are responsible for verification of EDI claims receipts. Acknowledgements for accepted or rejected claims received from Emdeon or other contracted EDI software vendors must be reviewed and validated against transmittal records daily. Since Emdeon returns acceptance reports directly to the sender, submitted claims not accepted by Emdeon are not transmitted to the plan. If you would like assistance in resolving submission issues reflected on either the Acceptance or 059 Plan Acceptance (laims Status) reports, contact the Emdeon Provider Support Line at 1.800.845.6592. ejected electronic claims may be resubmitted electronically once the error has been corrected. Invalid Electronic laim ecord ejections/ Denials All claim records sent to the plan must first pass Emdeon proprietary edits, HIPAA and plan-specific edits prior to acceptance. laim records that do not pass these edits are invalid and will be rejected without being recognized as received at the plan. In these cases, the claim must be corrected and resubmitted within the required filing deadline of 365 calendar days from the date of service. It is important that you review the Acceptance or 059 Plan Acceptance (laim Status) eports received from Emdeon or your EDI software vendor in order to identify and re-submit these claims accurately. laim status can be checked through the plan s Provider laims Service Unit s IV system by calling 1.800.575.0418 and following the prompts or through the NaviNet web portal. laims submitted successfully can be verified using the Acceptance and 059 Plan Acceptance (laim Status) eports. ontact your EDI software vendor or Emdeon to verify you receive the reports necessary to obtain this information. laims originally rejected for missing or invalid data elements must be corrected and resubmitted within 365 calendar days from the date of service. ejected claims are not registered as received in the claim processing system. (efer to the definitions of rejected and denied claims on page 5.) Emdeon will produce an Acceptance eport and a 059 Plan Acceptance (laim Status) eport for its trading partner whether it is the EDI vendor or provider. Providers using Emdeon or other clearinghouses and vendors are responsible for arranging to have these reports forwarded to the appropriate billing or open receivable departments. An Acceptance eport verifies acceptance of each claim at Emdeon. A 059 Plan Acceptance (laim Status) eport is a list of claims that passed Emdeon s validation edits; however, when submitted to the plan, encountered provider or member eligibility edits. Plan Specific Electronic Edit equirements The plan currently has two specific edits for professional (P) and institutional (I) claims sent electronically. 24 Select Health laims Filing Manual www.selecthealthofsc.com

837P 005010X098A1 Provider ID payer edit states the ID must be less than 13 alphanumeric digits. 837I 005010X096A1 Provider ID payer edit states the ID must be less than 13 alphanumeric digits. The plan s provider ID is to be sent as follows: 837P Loop 2310B, EF01* G2 qualifier, EF02 endering provider network ID 837I Loop 2310A, EF01 * G2qualifier, EF02 endering provider network ID You can contact the Emdeon Help Desk at 1.800.845.6592. equests for adjustments may be submitted by telephone to Provider laim Services at 1.800.575.0418. Administrative or medical appeals must be submitted in writing to: Select Health of South arolina, Attn: Appeals, P.O. Box 40849, harleston, S 29423. efer to the provider manual located in the Provider section online at www.selecthealthofsc.com for complete instructions on submitting administrative or medical appeals. orrected professional claims may be sent in on paper via MS 1500. Please stamp each claim submitted corrected or resubmission and send all corrected or resubmitted claims to: Select Health of South arolina, laims Processing Department, P.O. Box 7120, London, KY 40742; O corrected professional claims may be resubmitted electronically; refer to the section, orrected laims via EDI in this manual. orrected institutional claims can be resubmitted electronically using the appropriate bill type to indicate that it is a corrected claim. Example of a Professional Electronic laim Example of a Professional Electronic laim Field # Field Description Instructions and omments 1 Insurance Program Identification 1a Insured ID Number <Plan Name> Member s identification number 2 Patient s Name (Last, First, Middle Initial) 3 Patient s Birth Date/Sex 2000B, SB09 = I ommercial Insurance 2010BA/NM1 Use 2330A for OB Data 2010BA/NM1 New Born (2010A/NM1) 2010A/NM1 2010A/NM1 2010BA/DMG 2010A/DMG - Newborn equired or onditional* 4 Insured s Name (Last, First, Middle Initial) 2010BA/NM1 5 Patient s Address (Number, Street, ity, State, Zip) Telephone (Include Area ode) 2010BA/N3/N4 6 Patient elationship To Insured 2000/PAT01 7 Insured s Address (Number, Street, ity, State, Zip ode) Telephone (Include Area ode) Use 2330A for OB data N 8 Patient Status Blank N 9 Other Insured s Name (Last, First, Middle Initial) 2330A/NM1 9a Other Insured s Policy Or Group # 2320/SB *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. Electronic Data Interchange (EDI) for Medical and Hospital laims Example of a Professional Electronic laim 25

Example of a Professional Electronic laim Field # Field Description Instructions and omments equired or onditional* 9b Other Insured s Birth Date/Sex Not in IG N 9c Employer s Name Or School Name Not in IG N 9d Insurance Plan Name Or Program Name 2330 NM1 10a,b,c Is Patient s ondition elated To: 2300/LM11 10d eserved For Local Use Indicators may be submitted on the 837 Not in IG 2300/PWK N 11 Insured s Policy Group Or FEA # 2000B/SB 11a Insured s Birth Date/Sex 2010BA/DMG02 2010A/DMG02 11b Employer s Name Or School Name Not in IG N 11c Insurance Plan Name Or Program Name 2310/NM103 11d Is There Another Health Benefit Plan? 2000B/SB05 12 Patient s Or Authorized Person s Signature 2300LM10 2320/OI04 13 Insured s Or Authorized Person s Signature 2320/OI04 N 14 Date Of urrent: Illness (First Symptom) Or Injury (Accident) Or Pregnancy (LMP) 2300/DTP03 15 If Patient Has Same Or Similar Illness, Give First Date 2300 DTP 16 Dates Patient Unable To Work In urrent Occupation Not in IG N 17 Name Of eferring Physician Or Other Source 2310A/NM1 17a Other ID Number Of eferring Physician (Plan Provider ID#) 2310A/NM1 17b National Provider Identifier (NPI) (Enter the referring provider s NPI) 2310A/NM109. 18 Hospitalization Dates elated To urrent Services 2300/DTP 19 eserved For Local Use eserved for Nebraska Medicaid Provider ID Not in IG N 20 Outside Lab Not in IG N 21 22 23 Diagnosis Or Nature Of Illness Or Injury. (elate Items 1, 2, 3 Or 4 To Item 24E By Line) Medicaid esubmission ode Original ef. No. Used for Original laim # equired when LM05-3 (laim Frequency ode) indicates this claim is a replacement or void to a previously adjudicated claim. Prior Authorization Number eferral Number 2300, HIXX 2300/EF/Qualifier F8 2300/EF/Qualifier G1 2300/EF/ Qualifier 9F *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. N 26 Select Health laims Filing Manual www.selecthealthofsc.com

Example of a Professional Electronic laim Field # Field Description Instructions and omments 24A Date(s) Of Service See page 41 for supplemental guidance on the shaded portions of fields 24 A - J 2400/DTP equired or onditional* 24B Place Of Service 2300/LM05 24 EMG Not in IG N 24D Procedures, Services Or Supplies PT/HPS Modifier 2400/SV1 24E Diagnosis Pointer 2400/SV1 24F harges 2300/LM 24G Days Or Units 2400/SV1 24H EPSDT Family Plan 2400/SV1 24I ID Qualifier 2300/ 24J endering Provider ID *Select Health plan issued Provider ID number Strongly recommended 2310B NPI 2310B/EF01=G2 *equired when the endering Provider is an Atypical Provider and does not have an NPI number. 25 Federal Tax ID Number SSN/EIN of Billing Provider 2010AA/EF 26 Patient s Account No. 2300/ML01 27 Accept Assignment Not in IG N 28 Total harge Loop 2300/LM 29 Amount Paid OB data should be submitted as it was received from other payer 2300/AMT 2430/AMT 30 Balance Due 2430/AMT N 31 Signature Of Physician Or Supplier Including Degrees Or redentials / Date Not in IG an use Signature on File N 32 Name And Address Of Facility Where Services Were endered (If Other Than Home). NOTE: Ambulance information should be sent as per 837 IG 2310 2310D/2310E 2300/ & 1 32a. NPI number of Service Facility 2310D 32b. 33 Taxonomy code Submission of Taxonomy is strongly recommended Billing Provider Info & Phone # P.O. Box in the billing address will cause the claim to be rejected at the clearinghouse. P.O. Box may only be submitted with the Pay to Provider 33a. NPI number Billing Provider 2000A/PV 2010AA/NM1 2010AA/N3 2010AA/N4 2010AA/PE 2010AA equired unless Billing Provider is an Atypical Provider and is not required to have an NPI number. *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. N Electronic Data Interchange (EDI) for Medical and Hospital laims Example of a Professional Electronic laim 27

Example of a Professional Electronic laim Field # Field Description Instructions and omments equired or onditional* Taxonomy 33b. 2010BB/EF Strongly recommended *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. Example of an Institutional Electronic laim Example of an Institutional Electronic laim Field # Field Description Instructions and omments 1 2 Unlabeled field Billing provider name, address and telephone number Submission of taxonomy is strongly recommended Unlabeled field Billing provider s designated pay-to name and address 2010AA/NM1 201AA/N3 & N4 2000A Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 2010AB/N3 & N4 3a Patient ontrol No. 2300 LM01 3b Medical/Health ecord Number 2300/EF Qualifier EA 4 Type Of Bill LM05 5 Fed. Tax No. 2010AA 6 Statement overs Period From/Through 2300/DTP 8a Patient Identifier 2010BA 8b Patient Name 2010BA/NM1 9a-e Patient Address 2010BA 10 Patient Birth Date 2010BA/DMG 11 Patient Sex 2010BA/DMG 12 Admission 12 15 12 Admission Date 2300/DTP 13 Admission Hour 2300/DTP 14 Admission Type 2300/L1 Not equired 15 Source of eferral for Admission or Visit 2300/L1 Not equired 16 Discharge Hour (Date) 2300/DTP *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 28 Select Health laims Filing Manual www.selecthealthofsc.com

Example of an Institutional Electronic laim Field # Field Description Instructions and omments Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 17 Patient Discharge Status 2300/DTP 18-28 ondition odes HIXX where HI01= BG 29 Accident State 2300/EF 30 Unlabeled Field Not in IG N N 31a,b 34a,b 35a,b 36a,b Occurrence odes and Dates HIXX where H101 = BH Occurrence Span odes And Dates HIXX where H101 = BI 37a,b eserved Not in IG N N 38 esponsible Party Name and Address Not in IG N N 39a,b,c,d 41a,b,c,d Value odes and Amounts HIXX where H101 = BE 42 ev. d. 2400/SV2 43 evenue Description Not in IG N N 44 HPS/Accommodation ates/hipps ate odes 2400/SV2 45 Serv. Date 2400/DTP 46 Serv. Units 2400/SV2 47 Total harges 2300/LM0 48 Non-overed harges OB data should be submitted as received by other payer 2300/AMT01 49 Unlabeled Field Not in IG N N 50 Payer 2010BB/EF Plan Payer ID 51 Health Plan Identification Number Select Health Plan assigned Facility ID 2010BB Strongly recommended 52 el. Info Not in IG N N 53 Asg. Ben. Not in IG N N 54 Prior Payments Not in IG N N 55 Est. Amount Due Not in IG N N 56 National Provider Identifier Billing Provider 2010AA/NM1 *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. Electronic Data Interchange (EDI) for Medical and Hospital laims Example of an Institutional Electronic laim 29

Example of an Institutional Electronic laim Field # Field Description Instructions and omments 57 A,B, Other (Billing) Provider Identifier 2010BB/EF 2310A/EF QUALIFIE G2 Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 58 Insured s Name 2010BA/NM1 59 P. el If 2000/PAT01 60 Insured s Unique Identifier 2010BA/NM1 61 Group Name 2000B/SB 62 Insurance Group No. Not in IG N N 63 Treatment Authorization odes Not in IG N N 64 DN Use for submission of original claim number for adjusted or voided claims 2300/EF02 where EF01= F8 (Original eference number) 65 Employer Name Not in IG N N 66 Diagnosis and Procedure ode Qualifier (ID Version Indicator) Use ID qualifiers per IG Not equired Not equired 67 Prin. Diag. d. and Present on Admission (POA) Indicator 2300/HIXX Qualifier BK 67 A - Q Other Diagnosis odes 2300/HIXX Qualifier BF 68 Unlabeled Field Not in IG N N 69 Admitting Diagnosis ode 2300/HIXX Qualifier BJ 70 Patient s eason for Visit 2300/HIXX Qualifier P 71 Prospective Payment System (PPS) ode 2300/HIXX Qualifier D 72a-c External ause of Injury (EI) ode 2300HIXX Qualifier BN 73 Unlabeled Field Not in IG N N 74 Principal Procedure code and Date 2300/HIXX Qualifier B 74a-e Other Procedure odes and Dates 2300/HIXX Qualifier BQ 75 Unlabeled Field Not in IG N N 76 Attending Provider Name and Identifiers NPI#/ Qualifier/Other ID# Enter the NPI number of the attending physician Attending Provider is required 2310A/NM1 2310/EF Qualifier G2 *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. 30 Select Health laims Filing Manual www.selecthealthofsc.com

Example of an Institutional Electronic laim Field # Field Description Instructions and omments 77 78 79 Operating Physician Name and Identifiers NPI#/ Qualifier/Other ID Enter the NPI number of the physician who performed surgery Other Provider (Individual) Names and Identifiers NPI#/Qualifier/Other ID# Enter the NPI number of another attending physician Inpatient, Bill Types 11X, 12X, 21X, 22X, 32X equired or onditional* Outpatient, Bill Types 13X, 23X, 33X 83X equired or onditional* 2310B/NM1 2310/NM1 80 emarks Field 2300/NTE 81,a-d ode-ode Field Not in IG N N *equired () fields must be completed on all claims. onditional () fields must be completed if the information applies to the situation or the service provided. Exclusions ertain claims are excluded from electronic billing. These exclusions fall into two groups: Excluded laim ategories At this time, these claim records must be submitted on paper. Excluded Provider ategories laims issued from or on behalf of the following providers must be submitted on paper. These exclusions apply to inpatient and outpatient claim types. Exlcuded laim ategories laim records for medical, administrative or claim appeals. Excluded Provider ategories Excluded provider categories. Providers not transmitting through Emdeon or providers sending to vendors that are not transmitting through Emdeon. Non-Emergent transportation. Pharmacy (through Emdeon). Although Emdeon does not reject the plan s unique state and local PT coding guidelines at this time; this may change due to HIPPA regulations. ontact your EDI software vendor, the Emdeon Help Desk or Provider laim Services if you have not been notified of impending changes or it you wish to discuss limitations encountered after implementation. ontact the Emdeon Help Desk at: 1.800.845.6592 ontact Provider laim Services at: 1.800.575.0418 ommon ejections Invalid Electronic laim ecords ommon ejections from Emdeon laims with missing or invalid batch level records. laim records with missing or invalid required fields. laim records with invalid (unlisted, discontinued, etc.) codes (PT-4, HPS, ID, etc.). laims without provider numbers. laims without member numbers. laims in which the date of birth submitted does not match the member ID. laims submitted with a PO Box in the billing provider address field (box 33). Invalid Electronic laim ecords ommon ejections from the Plan (EDI Edits within the laim System) laims received with invalid provider numbers. laims received with invalid member numbers. laims received with invalid member date of birth. Electronic Data Interchange (EDI) for Medical and Hospital laims Exclusions 31

NOTE: Provider identification number or NPI number validation is not performed at Emdeon. Emdeon will reject claims for provider information only if the provider number or NPI fields are empty. 835 Electronic emittance Advice Select Health has partnered with Emdeon and HDX as clearinghouses for the 835 electronic remittance advice transactions. Emdeon and HDX are leaders in processing transactions for vendors, providers and health plans in the HIPAA compliant standardized formats. Providers may choose either clearinghouse from which to receive their 835 Electronic emittance Advice. The provider s current EDI vendor should be contacted for additional information prior to contacting HDX or Emdeon. Providers should be prepared to supply the following information during the set-up phase: EDI/vendor and submitter ID Group/facility name ontact name, phone number and e-mail address Address Tax ID Payee ID A copy of the 835 ompanion Guide can be found under Provider section of Select Health s website under HIPAA Information. Additional assistance may be found by contacting Provider laim Services at 1.800.575.0418. Payer EA enrollment forms and payer registration forms are located at www.emdeon.com. HDX.com HDX ontact Information: 1.610.219.3331 Emdeon Help Desk: 1.800.845.6592 HDX Electronic emittance Service: ESPayers@ Electronic Billing Inquiries Inquiry Topic ontact Transmitting claims electronically Emdeon Help Desk at 1.800.845.6592 General EDI questions Provider laim Services at 1.800.575.0418 Specific claims transmissions or acceptance and 059 laim Status reports Your EDI Software Vendor or the Emdeon Help Desk at 1.800.845.6592 059 laim Status receipt or completion dates Provider laim Services at 1.800.575.0418 laims that are reported on the emittance Advice Provider laim Services at 1.800.575.0418 Provider ID or NPI number needed Provider laim Services at 1.800.575.0418 Update provider, payee, NPI, UPIN, tax ID number or payment address information or changing or verifying provider information Select Health of South arolina Provider Services PO Box 40849 harleston, S 29423 Fax: 843.569.0702 Phone: 1.800.741.6605 835 emittance Advice Your EDI Vendor heck the status of your claims NaviNet at www.navinet.net Sign up for NaviNet www.navinet.net or NaviNet ustomer Service: 1.888.482.8057 32 Select Health laims Filing Manual www.selecthealthofsc.com

How to Minimize etrospective hart eview Why are retrospective chart reviews necessary? Although Select Health captures information through claims data, certain diagnosis information is commonly contained in medical records but is not reported via claim submission. omplete and accurate diagnosis coding will minimize the need for retrospective chart reviews. Tips for Accurate Diagnosis oding What is the significance of the ID M diagnosis code? International lassification of Diseases linical Modification codes are identified as three- to five-digit codes used to describe the clinical reason for a patient s treatment and a description of the patient s medical condition or diagnosis (rather than the service performed). hronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s). Do not code conditions that were previously treated and no longer exist. However, history codes (V10-19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment. Per the ID-M Official Guidelines for oding and eporting (Oct. 1, 2010), providers must code all documented conditions that were present at time of the encounter/visit and require or affect patient care treatment or management. Have you coded for all chronic conditions for the member? Examples of disease conditions that should always be considered and included on the submission of the claim if they coexist at the time of the visit: Amputation status Diabetes mellitus Multiple sclerosis Bipolar disorder AD erebral vascular disease hronic renal failure ongestive heart failure OPD Depression Dialysis status Drug/alcohol dependence Drug/alcohol psychosis HIV/AIDS Hypertension Lung, other severe cancers Metastatic cancer, leukemia Paraplegia Quadriplegia enal failure Schizophrenia Simple chronic bronchitis Tumors, other cancers (prostate, breast, etc.) What are your responsibilities? Physicians must accurately report the ID-M diagnosis codes to the highest level of specificity. For example, a diabetic with neuropathy should be reported with the following primary and secondary codes: 250.60 Diabetes with neurological manifestations and 357.2 for diabetic polyneuropathy Accurate coding can be easily accomplished by keeping accurate and complete medical record documentation. Documentation Guidelines eported diagnoses must be supported with medical record documentation. Acceptable documentation is clear; concise, consistent, complete and legible. Physician Documentation Tips First list the ID M code for the diagnosis, condition, problem or other reason for the encounter visit shown in the medical record to be chiefly responsible for the services provided. Adhere to proper methods for appending (late entries) or correcting inaccurate data entries, such as lab or radiology results. Electronic Data Interchange (EDI) for Medical and Hospital laims How to Minimize etrospective hart eview 33

Strike through, initial and date. Do not obliterate. Use only standard abbreviations. Identify patient and date on each page of the record. Ensure physician signature and credentials are on each date of service documented. Update physician super bills annually to reflect updated ID M coding changes and the addition of new ID M codes. Physician ommunication Tips When used, the SOAP note format can assist both the physician and record reviewer/coder in identifying key documentation elements. SOAP stands for: Subjective: How the patients describe their problems or illnesses. Objective: Data obtained from examinations, lab results, vital signs, etc. Assessment: Listing of the patient s current condition and status of all chronic conditions. eflects how the objective data relate to the patient s acute problem. Plan: Next steps in diagnosing problem further, prescriptions, consultation referrals, patient education and recommended time to return for follow-up. 34 Select Health laims Filing Manual www.selecthealthofsc.com

EOB Denial odes This list is not all inclusive. Denial ode GO DD DUP I06 I09 I10 I11 I13 I20 IAA N13 PAK PS PS2 PSO PSS Q11 A7 00 01 15 35 39 45 47 51 82 S13 S23 Denial Description 96: Tier not found, ategory not covered 18: Definite Duplicate laim B13: Duplicate Denial 16: lm Pend: Itemized bill required 47: Diag Inv/Missing/Deleted/eq 4th/5th 47: Eode cannot be used as primary diag. 148: lm Pend: EOB from prim carrier req 148: lm Pend: EOB/attach illeg/incomplete Denied laim Disallow B3: ITS Lil allowable amount B18: Invalid procedure disallow 42: Exceeds per diem rate 94: Exceeds service amount 119: Exceeds the maximum number of units B1: Not a covered service 42: Exceeds the scheduled rate 63: laim previously processed incorrectly B1: Vaccine supplied by VF 97: Payment included in other billed service 62: No precert/authorization or referral 97: Subset/incidential procedure disallow 39: Authorization denied for this DOS B13: Dup laim prev pd at correct rate / a B12: omplete Med ecords eq d 23: Pymt reflects OB, if $0, max liab me B1: Service not covered 16: Individual prov ID must be submitted 26: All enroll events are future 26: Date req. Prior to subscriber eff date Denial ode ST TFO T5 UM1 UM3 UMO X00 X01 X10 X11 X35 X39 X45 X50 X53 X68 X77 X90 X91 X96 X98 Z01 Z11 Z38 Z41 Z45 Z47 Z92 Z99 Denial Description 27: Termination 29: Submitted after plan filing limit 96: overed ounter >SrvAllowtr+rel hist 62: Units exceed UM authorization 16: Pended Status, Zero Units 39: Services Disallowed by UM 97: Payment included in other billed service 62: No precert/authorization or referral 31: Not enrolled on date of service 148: lm Pend: EOB from prim carrier req 39: Authorization denied for this DOS B13: DuplaimPrevPd at correct rate/cap 16: lm Pend: complete med recs req d 18: Same procedure Pd to different prov 112: Services were not provided 57: Invalid units submitted 16: Incorrect provider/tin ID # submitted 16: UB dates of service required B7: inappropriate coding for contract/ agreement 148: lmpend: EOB/attach illeg/incomplete B7: inappropriate coding for contract/ agreement 109: Medicaid Fee-for-Service 148: lm Pend: EOB from prim carrier req B18: Missing/ Illeg procedure/revenue code B18: Missing/ Illeg ID procedure code B12: AmbulanceunSheet req for processing 109: Medicaid Fee-for-Service 5: Invalid or missing place of service 8: ode not payable for provider specialty Electronic Data Interchange (EDI) for Medical and Hospital laims EOB Denial odes 35

Appendix - Supplemental Information Ambulance laims Ambulatory Surgery laims Anesthesia laims Behavioral Health laims hiropractic laims Durable Medical Equipment (DME) laims Early, Periodic, Screening and Diagnostic Testing (EPSDT) laims Home Health are (HH) laims Infusion Therapy and Injectable Drugs laims Maternity laims Multiple Surgical eduction Payment Policy Nursing Home laims Physical/Occupational and Speech Therapy laims enal Dialysis laims 36 Select Health laims Filing Manual www.selecthealthofsc.com

Ambulance laims All transportation services, Advanced Life Support (ALS) or Basic Life Support (BLS) either emergency or non-emergency, provided via ambulance are payable by Select Health. These trips may be routine or non-routine transports to a Medicaid covered service. overage also includes stretcher trips, as well as air ambulance or medivac transportation. Ground and air ambulance services are billed on MS 1500 or 837 Format. When billing procedure codes for ambulance transportation services, the provider must also enter a valid two-digit modifier at the end of the associated fivedigit procedure code. Providers must bill the transport codes with the appropriate destination modifier. laims submitted without a destination modifier will be denied for invalid/missing modifier. Mileage must also be billed with the ambulance transport code and be billed with the appropriate procedure codes. Mileage when billed will only be paid in conjunction with a PAID transport code. Providers who bill mileage alone will be denied for invalid/inappropriate billing. For 837 claims, all ambulance details are required: ambulance transport information, ambulance certification, pick-up and drop-off locations. Procedure ode Destination Modifiers The following procedure code modifiers are required with all ambulance procedure codes. The first place alpha code represents the origin, and the second place alpha code represents the client s destination. odes may be used in any combination unless otherwise noted. D - Diagnostic or therapeutic site (other than physician s office or hospital) E - esidential, domiciliary or custodial facility (other than skilled nursing facility) G - Hospital-based dialysis facility (hospital or hospital-related) H - Hospital I - Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport N - Skilled nursing facility P - Physician s office (includes HMO non-hospital facility, clinic, etc.) - esidence S - Scene of accident or acute event 76 Duplicate procedure, same day of service NT No transport EV Evacuation Authorization equirements For Ambulance Services Services equiring Authorization Hospital to hospital (transfer) Transports to doctor s appointments Hospital or facility discharge Air transport Services Not equiring Authorization Emergent and non-emergent ambulance transports whether ALS or BLS Ambulance Services Not overed Ambulance transports requested after the member is pronounced dead Ambulance transports to a coroner s office, morgue, funeral home or any other nonmedical facility Free ambulance services onvenience transports Intra-facility transports Inpatient hospital services (offsite) When a member remains an inpatient of the hospital, all services rendered to the member, including ambulance transports, are included in the hospital DG payment. (For example, if a member remains on the census as an inpatient at Hospital A and is only traveling to Hospital B for a diagnostic test or procedure not available at A, the DG Facility is responsible). Ambulance providers and the hospital facility should determine payment procedures when rendering services to an inpatient beneficiary. J - Non hospital-based dialysis facility Appendix - Supplemental Information Ambulance laims 37

Ambulatory Surgery laims An ambulatory surgery center (AS) is a distinct entity that operates exclusively for the purpose of providing surgical services to patients who are scheduled to arrive, receive surgery and discharged on the same day. Authorization requirements for AS claims are based on the services performed. laims must be billed on a MS 1500 form. eimbursement is based on the procedure code billed, with the code generating the highest reimbursement paying at 100 percent of the allowable amount. All other procedure codes will pay at 50 percent of the allowable amount. Anesthesia laims Anesthesiology is the study of how to produce loss of bodily sensation. Anesthesia is generally administered in an inpatient or SPU setting. eimbursement for anesthesia claims is based on the total amount of time the anesthesia was administered to the patient. All anesthesia services (participating and non-participating) are payable without an authorization regardless of the place of service with the exception of pain management. Anesthesia providers must bill with the appropriate anesthesia (ASA) procedure code. If a surgical procedure code is billed, the claim will be denied. Anesthesia claims are to be billed with the actual minutes in the units field. ertified egistered Nurse Anesthetists (NA) A NA is a registered nurse with additional training to administer anesthesia under the direction of the anesthesiologist. NAs can be paid in addition to the anesthesiologist. Some PT codes are payable to anesthesiologists only and not NAs. Modifiers The following modifiers may be billed with anesthesia services: Modifier Description eimbursement ate AA Anesthesiologist personally performed services. 100 percent of anesthesiology rate AD QK QS QX Medically supervised by a physician for more than four concurrent procedures. Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals. Monitored anesthesiology care services (can be billed by a NA or an anesthesiologist). NA with medical direction by an anesthesiologist. This modifier should be billed for NAs only. 100 percent of anesthesiology rate with standard of three base units 60 percent of anesthesiology rate 100 percent of appropriate provider rate 50 percent of anesthesiology rate QY Medical direction of one NA by an anesthesiologist. 60 percent of anesthesiology rate QZ NA without medical direction by an anesthesiologist. This modifier should be billed for NAs only. 100 percent of anesthesiology rate Behavioral Health laims The mental/behavioral health benefit includes the professional and outpatient facility charges associated with the Medicaid covered behavioral health services. Identifying Mental Health laims For MS-1500 claims, the PT code identifies the claim as mental health. For UB04 claims, the ID diagnosis code identifies the claim as mental health. 38 Select Health laims Filing Manual www.selecthealthofsc.com

Provider Types Licensed Independent Practitioners (LIPs) Medical Professionals Other Psychologists Psychiatrists Federally Qualified Health enters (FQH) Marriage and family therapists Physicians ural Health linics (H) Professional counselors Nurse practitioners Acute are Hospitals Independent social workers Authorization equirements Authorization is required for services rendered by LIPs and psychiatrists for: Inpatient psychiatric care Inpatient detoxification or rehabilitative substance abuse care Electroconvulsive therapy (ET) inpatient or outpatient Psychological testing, neuropsychological testing Outpatient psychiatric or behavioral health care Outpatient substance abuse Authorization is not required for: Assessment codes 90791, 90792, H0002 and H2000 Behavioral Health PT codes (listed above) rendered by medical professionals o-pays Psychiatric diagnostic assessment with/without medical evaluation 90791, 90792 for adults (ages 19 and over) $3.30 No other co-pays or deductibles for persons receiving behavioral health services Labs All lab services billed by the participating provider are payable without an authorization. Outpatient Behavioral Health in the E For outpatient services in an emergency room (E) setting with behavioral health (class code) primary diagnosis code, the E visit (both professional and facility fees) are covered. Inpatient Behavioral Health DGs Medical services rendered to patients admitted with a psychiatric diagnosis are payable. The following inpatient psychiatric AP-DGs are payable by Select Health: 7401-7404 7501-7604 7701-7764 H/FQH Behavioral Health claims Hs and FQHs can bill behavioral health services and a regular E/M encounter on the same date of service. The H and FQH medical providers (MD, NP and specialists) are not subject to prior authorization requirements when billing behavioral health PT codes. The H and FQH LIPS providers (LP, SW, psychologists, including psychiatrists and child psychiatrists) must follow the authorization requirements: No authorization is required for assessment codes: 90791, 90792, H0002, and H2000. All other codes require an authorization. laims are submitted using standard ID and PT coding. laims submitted with T codes should be denied. laims may be billed using the following place of service codes: 11, 22, 50 or 72. laims are paid at the Medicaid fee-for-service rate. Providers will receive their reconciliation payment from the state. Behavioral Health services covered by Medicaid fee-for-service All claims in which services are provided or referred by the following state agencies are paid by Medicaid fee-for-service: Department of Education Appendix - Supplemental Information Behavioral Health laims 39

Department of Behavioral Health Department of Juvenile Justice Department of Social Services ontinuum of are for Emotionally Disturbed hildren Department of Disabilities and Special Needs South arolina School for the Deaf and the Blind Sickle ell Foundation Home and ommunity-based Waiver Services Also services rendered at the following places of service are paid by Medicaid fee-for-service: Private esidential Treatment Facilities (PTF) Developmental Evaluation enters (DE) Adolescent Treatment Facilities (ATF) hiropractic laims hiropractic services are available to all recipients hiropractors specialize in the detection and correction of structural imbalance, distortion or subluxation in the human body. Select Health will cover authorized services up to six visits per state fiscal year (July 1 June 30). Authorizations All chiropractic services must be prior authorized. To obtain prior authorization, contact Medical Services at 1.888.559.1010. laim Submission Select Health contracts with Health Network Solutions, Inc. (HNS) to provide administrative services for our hiropractic network. laims are submitted on a MS 1500 claim form. Submit claims directly to HNS through HNSonnect claims filing system, except for corrected claims or claims with attachments. When filing claims the following information must be provided: First hoice should be in box 11. Select Health or First hoice should be in box 11c. Prior authorization number must be in box 23. laims submitted without the authorization number will be rejected on the front end. If there was a referral from the PP, (not required) boxes 17 and 17b must be completed. laims must be identified as Select Health claims at the tip of the MS 1500 form, even when submitting electronically, see the format below: HNS/Select Health P.O. Box 2368 ornelius, N 28031 laims inquiries To obtain information on outstanding claims (60 days from filing date), complete the HNS fax inquiry form and fax to HNS. The form can be obtained by visiting the HNS website at: http://healthnetworksolutions.net/index. php/compliance/hns-forms under Administrative forms or in the appendix of this manual. Be sure to include the member s names, date of birth, ID number and the dates of service in question, and HNS will research your claim and respond back to you within three business days. Eligibility and benefits inquiry Be sure to always verify eligibility and benefits for each plan member by contacting Member Services at 1.888.276.2020 or by visiting the NaviNet provider web portal at: www.navinet.net. If you are not registered with NaviNet, you can complete the registration when you visit the website. Provider elations Questions relating to your participation with Select Health should be directed to your HNS service representative at 1.877.426.2411. Durable Medical Equipment (DME) laims DME (durable medical equipment) is equipment and supplies that are used in the member s home. Some common examples are: Wheelchairs Oxygen concentrators Enteral therapy supplies Adult diapers Prosthetics Orthotics Billing equirements DME is generally billed on a MS 1500 form. Providers may bill for more than one service on a claim. Services are billed with HPS procedure codes. eimbursement Types DME equipment is reimbursed as one of the following: Purchase - Equipment and supplies that are paid in full 40 Select Health laims Filing Manual www.selecthealthofsc.com

upon receipt, not in monthly increments. Examples of DME purchases are enteral formula, gauze and tape. ent-to-purchase - Equipment that is reimbursed in monthly increments until the purchase price of the item is met. Examples of rent-to-purchase equipment are standard wheelchairs and beds. Equipment is rented for a maximum of 10 months; the item is considered purchased thereafter. Select Health does not reimburse for maintenance fees. Ongoing ental - Equipment that is reimbursed on a monthly basis and does not have a purchase price. Examples of ongoing rentals are oxygen concentrators and ventilators. Authorization equirements For participating providers, authorization is required for items with billed charges of $500 or greater per DME item. Non-participating providers require an authorization for all services regardless of charge. All leases and rentals require prior authorization. Modifiers The following modifiers may be billed on DME claims: vision, hearing, dental, growth and development, nutrition, etc. Screenings can be performed by the member s PP, pediatrician or local health department. Billing Guidelines EPSDT claims are submitted on the MS 1500 claim form. laims are billed using PT procedure codes. Do not bill claims using EPSDT as the procedure code. Do not bill an EPSDT E/M code and another office visit code on the same date of service. Labs are paid in addition to the reimbursement for the EPSDT screening. Always use V20.2 as the primary diagnosis. If a problem is detected use the appropriate ID diagnosis code as the secondary diagnosis. Immunizations oding for Members 19 and Older 90471 One immunization 90472 Each additional immunization Use 90472 in conjunction with 90471. This code can only be used twice per visit, regardless of the number of additional vaccines administered. Modifier LL NU UE Description ental Lease/rental (applied to purchase) New equipment Used equipment oding for Intra-Nasal/Oral Immunization Administration 90473 One immunization 90474 Each additional immunization Use 90474 in conjunction with 90473. This code can only be used twice per visit regardless of the number of additional vaccines administered. Enteral Therapy Parenteral, enteral nutrition therapy and feeding supplies are payable if authorized. Nebulizers Nebulizers are covered as purchase only. Early, Periodic, Screening and Diagnostic Testing (EPSDT) laims First hoice participates in the Early and Periodic Screening Diagnosis and Treatment (EPSDT) program, which benefits children from birth to age 21. The program provides for the screening of the following areas of children s health: oding for members under the age of 19 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component (one unit per date of service). 90461 Each additional vaccine/toxoid component (two units per date of service). Additional Billing Notes If you detect a health problem during a well visit, do not change the coding from a well exam to a sick visit if the well-visit components can be completed. When billing, use V20.2 as the first diagnosis. The second diagnosis is Appendix - Supplemental Information Early, Periodic, Screening and Diagnostic Testing (EPSDT) laims 41

then determined by the detected problem. If other medically necessary elective tests or procedures (not required elements of the EPSDT visit) are performed during the EPSDT visit, they may be billed additionally. When separate procedures are performed, append a 25 modifier on the EPSDT code. All required elements of the EPSDT visit (a blood pressure check, hearing screening, etc.) are included in your reimbursement rate and should not be billed separately. A sports physical may qualify as an EPSDT screening as long as all components are Included in the exam. Laboratory tests are not part of the screening package and may be billed and reimbursed as additional claim lines. The screening blood lead test is required as part of EPSDT services. The finger or heel stick collection of the blood sample is covered by the EPSDT rate. However, the lab analysis is covered as a separate service. If your office sends the blood lead samples to an outside laboratory for analysis, the lab should bill directly for the analysis using PT code 83655. If your office analyzes the blood lead samples internally, your office should bill for this service using PT code 83655. Modifiers 01 and 02 are not required for EPSDT claim submission. Primary care physicians can bill for topical fluoride varnish treatments, PT code D1206 as part of the EPSDT exam. laims for VF vaccine administration must include: The appropriate vaccination product PT code The appropriate vaccination administration code For this code combination, only the administration code will be reimbursable when billing Select Health Federally Qualified Health enters (FQHs) and ural Health enters (Hs) must also submit these administration and PT codes for the vaccination products. A recent change to procedure-to-procedure (PTP) edits affects claims for immunization administration and evaluation and management (E&M) codes performed on the same date of service. The immunization administration codes affected by the new PTP edits are PT codes in the range of 90460, 90461, 90471 90474. All E&M services PT codes, including preventive medicine services (i.e. well child or EPSDT visits), are impacted by the PTP edit. Immunization administration codes and E&M services can be reported together when a 25 modifier is appended to the E&M code. Documentation in the medical record should support the use of an appropriate modifier. When billing for vaccines that are not covered under the VF program or for beneficiaries over the age of 19, the provider may bill for the vaccine and the administration codes 96372, 90471 90474. Home Health Home health claims are comprised of the following services: skilled nurse visits, home health aide visits, physical, occupational, speech therapy visits. Members are entitled to a total of 50 visits per calendar year. Authorizations requirements The first six home health visits do not require prior authorization. Services rendered after the first six do require prior authorization. o-pays There is a $3.30 copay for home health services. Same day visits Two nursing care visits performed on the same date of service are payable when billed with procedure code T1030 or T1031 and modifier 76 is indicated on the second visit. Billable Procedure odes: T1030 Nursing care by a registered nurse T1031 Nursing care by a licensed practical nurse T1031 Nursing visit - stabilized patient T1028 Assessment visit - DME evaluation T1021 Home health aide visit A9900 Supplies S9127 Social work services to enhance the effectiveness of home health S9128 Speech therapy 42 Select Health laims Filing Manual www.selecthealthofsc.com

S9129 Occupational therapy S9131 Physical therapy Home Infusions and Injectable Drugs laims All drugs billed are required to be submitted with ND information and may be submitted via a MS-1500 or 837 electronic format. laims submitted without ND information will be denied. Authorization requirements An authorization is required for all J codes (including J3490) billed over $250. Family Planning codes The following procedure codes are considered family planning and will automatically deny Z01 Medicaid fee-for-service: J1051 J1055 J1056 J7300 J7302 J7303 J7304 Maternity laims Maternity laims are claims billed by the OB/GYN for prenatal, delivery and postnatal care. Authorization equirements When a member is identified as being pregnant, the OB/ GYN is required to obtain an authorization that will cover all OB and postpartum services performed in the office. Providers obtain authorization by submitting a Prenatal isk Assessment Form, which is located in the Exhibits section of this manual and is also available on the Select Health website, www.selecthealthofsc.com in the Provider forms section. The Prenatal isk Assessment Form: Should be completed on every pregnant member. Assists in early identification of the high-risk pregnancy for case management. Is used to create the maternity authorization necessary for payment of prenatal services. Providers can bill PT code 99420 and be reimbursed $15 for the completion of this form. this authorization has been obtained. Prior authorization may be required for other services (e.g. testing) rendered outside of the OB provider s office. Providers should always check with Medical Services, 1.888.559.1010, for authorization requirements. Ultrasounds Three ultrasounds are allowed without authorization for participating providers. Four or more, while authorization is still not required, will require a high-risk diagnosis. This requirement applies to all OB providers including maternal fetal medicine. 17-P Injections Select Health does pay for 17-P injections for women who meet the medical necessity criteria. Prior authorization is also required. Please fax the completed Universal 17-P Authorization Form (see Exhibits section in this manual or visit the website), to 1.866.533.5493 along with a signed prescription. all Medical Services at 1.888.559.1010 if you have questions. Nurse Midwives Nurse midwives (NMs) are payable under the authorization for the delivery. ertified nurse midwives (NMs) are payable at 100 percent of the physician s rate. Licensed midwives (LM) are payable at 65 percent of the physician s rate and should be billed with modifier SB. There are no limitations on postpartum services rendered by a midwife. oordination of Benefits and o-pays For plan members, co-pays do not apply to maternity services. Select Health does not pay global maternity procedure codes. If the member has a primary insurance that pays based on global maternity codes, Select Health will pay the difference between our maximum allowable for all routine maternity services and the amount paid by the primary carrier for the global maternity service, provided that this difference does not exceed the member s liability (including co-pay, coinsurance/deductible and other amounts). A separate authorization is required for the delivery. The hospital is responsible for obtaining the delivery authorization; however, physician offices should verify that Appendix - Supplemental Information Home Infusions and Injectable Drugs laims 43

Screening, Brief Intervention and eferral to Treatment (SBIT) SBIT is a component of the SDHHS Birth Outcome Initiative (BOI) program with the primary goal to improve birth outcomes and overall health of the moms and babies in South arolina. It is the screening and treatment program for pregnant Medicaid enrollees that addresses the treatment of substance abuse. Screenings are administered by clinicians: Physicians Physician assistants Nurses Social workers Behavioral health therapists Nurse practitioners Medical assistants Screenings are performed using the Institute for Health and ecovery Integrated (IH) Screening Tool. It s located in the Exhibits section of this manual and on the Select Health website. Only screenings performed using this tool may be billed. ompleted screening tool should be maintained in the patient s medical record. All completed screening tools, positive or negative must be faxed to the health plan Billing SBIT services SBIT services must be billed under the physician s provider ID/NPI number. Primary DX should be pregnancy related Secondary DX code must be V82.9 Screening for Unspecified ondition Behavioral screening ode H0002 U1 One per year (olling 12 months) eimbursement per screening = $24.00 Brief Intervention ode H0004 U1 Two thirty-minute units per year eimbursement per unit = $48.00 For Select Health, the H/FQH bills PT/HPS codes to the plan; therefore, for SBIT the FQH/H will: Submit the H0002 U1 and H0004 U1 codes in addition to the encounter Primary DX should be pregnancy related Secondary DX code must be V82.9 Screening for Unspecified ondition For smoking cessation visits: Services must be one-on-one and face-to-face between the provider and the member ode claims with: DX code 305.1 Tobacco Use disorder Appropriate E&M code Preventive medicine treatment (99381-99397) New patient codes (99201-99205) Established patient codes (99211-99215) Services provided by an allied health professional: ode up to a level two office visit (99212) Must be billed under the supervising physician s ID Outpatient hospitals may also bill: Behavioral screening ode H0002 U1 Brief intervention ode H0004 U1 For additional information or to set up SBIT training for your office, contact your Network Management Account Executive. Multiple Surgical eduction Payment Policy Multiple procedures performed at the same operative session are separately reportable and billable. When multiple procedures are performed, the major procedure is submitted without a modifier secondary procedures must be submitted with modifier 51 (unless the secondary codes are add-on or modifier 51 exempt codes). The procedure code generating the highest reimbursement will be paid at 100 percent of the allowable amount. All other procedure codes will be paid at 50 percent of the allowable amount. Bilateral procedures are those performed on both the right and left side of the body or organ. Providers should bill bilateral procedures on two lines using modifier 50 on the second line item. The procedure code billed without modifier 50 will be paid at 100 percent of the allowable amount and The procedure code billed with the modifier will be paid at 50 percent of the allowable. 44 Select Health laims Filing Manual www.selecthealthofsc.com

Nursing Home laims Under the contract between Select Health and SDHHS, there is a provision that requires MOs to provide coverage for our members for the first 90 days of continuous confinement in a long-term care facility or nursing home. Additionally, the MO is responsible for long-term care until the member can be disenrolled at the earliest effective date allowed, at which time payment for longterm care services will be reimbursed at the fee-for-service rate by the Medicaid program. The maximum MO liability is a total of 120 days. Authorization equirements For prior authorization of services, contact Medical Services at 1.888.559.1010. laim submission guidelines Submit charges on a UB-04 claim form Use revenue codes 120 and 121 For claims questions, contact the Provider laims Service enter at 1.800.575.0418 For additional information, contact your Network Management Account Executive. Physical, Occupational and Speech Therapy laims Therapy services are provided by physicians/specialists in the rehabilitation of physical impairments and disease. Physicians and specialists may bill therapy along with evaluation and management services and/or diagnostic services. Types of therapy include physical, occupational and speech. Therapy services are limited to 420 units or 105 hours combined per fiscal year. The fiscal year begins July 1 and ends June 30 of each year. This applies to both private rehabilitative providers as well the outpatient hospital clinic speech therapy. odes 92507 and 92508 will require prior authorization; this requirement will not apply to the evaluation codes (S9152 and 92506-HA). Speech therapy providers will be required to submit the authorization request prior to services being rendered. Medical necessity must be supplied for initial requests. An IEP is not required, but we will need evidence of coordination with school-based therapists. For ongoing treatment, the request should include progress notes, goals and the MD order. enal Dialysis laims enal dialysis is a form of medical treatment that removes the body s wastes and excess water directly from the blood. Select Health s plan members may receive renal dialysis for the treatment of end-stage renal disease (ESD). ESD refers to a stage of kidney damage at which clinical intervention is required. If there is no clinical intervention, the patient will expire. Patients with ESD are faced with two treatment alternatives. The first alternative is a kidney transplant. Due to the lack of donor kidneys, most patients choose renal dialysis. Dialysis claims must be billed on a MS 1500 form. Providers are not required to submit an itemized claim. Dialysis may be administered in an inpatient/outpatient hospital setting or in a dialysis clinic (POS 65). Authorization requirements enal dialysis services/treatments do not require an authorization regardless of the provider s participation status. However, authorization is required for dialysis related J codes with billed amounts $250 and over. The J codes must also be billed with the National Drug ode (ND) number and drug name. These requirements apply to both participating and non-participating providers. This prior authorization requirement is not applicable to speech therapy rendered at an outpatient hospital. For an outpatient hospital, the first 12 visits and the evaluation do not require prior authorization, and the appropriate PT code must accompany the revenue code on claim submissions. This requirement applies to all therapy disciplines; physical, occupational and speech, rendered at the outpatient hospital. Appendix - Supplemental Information Nursing Home laims 45

Exhibits MS 1500 Form HNS Fax Inquiry Form Institute for Health and ecovery Integrated (IH) Screening Tool (SBIT) Prenatal isk Assessment Form UB-04 Form Universal 17-P Authorization Form 46 Select Health laims Filing Manual www.selecthealthofsc.com

MS 1500 Form 1500 HEALTH INSUANE LAIM FOM APPOVED BY NATIONAL UNIFOM LAIM OMMITTEE 08/05 PIA 1. MEDIAE MEDIAID TIAE HAMPVA GOUP FEA OTHE HAMPUS HEALTH PLAN BLK LUNG (Medicare #) (Medicaid #) (Sponsor s SSN) (Member ID#) (SSN or ID) (S SN) (ID) PIA 1a. INSUED S I.D. NUMBE (For Program in Item 1) AIE 2. PATIENT S NAME (Last Name, First Name, Middle Initial) 5. PATIENT S ADDESS (No., Street) 3. PATIENT S BITH DATE MM DD YY SEX M F 6. PATIENT ELATIONSHIP TO INSUED Self Spouse hild Other 4. INSUED S NAME (Last Name, First Name, Middle Initial) 7. INSUED S ADDESS (No., Street) ITY ZIP ODE TELEPHONE (Include Area ode) 9. OTHE INSUED S NAME (Last Name, First Name, Middle Initial) a. OTHE INSUED S POLIY O GOUP NUMBE c. EMPLOYE S NAME O SHOOL NAME d. INSUANE PLAN NAME O POGAM NAME F EAD BAK OF FOM BEFOE OMPLETING & SIGNING THIS FOM. 12. PATIENT S O AUTHOIZED PESON S SIGNATUE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. SIGNED DATE 14. DATE OF UENT: MM DD YY 19. ESEVED FO LOAL USE ( ) b. OTHE INSUED S DATE OF BITH MM DD YY M ILLNESS (First symptom) O INJUY (Accident) O PEGNANY(LMP) STATE 15. IF PATIENT HAS HAD SAME O SIMILA ILLNESS. GIVE FIST DATE MM DD YY 21. DIAGNOSIS O NATUE OF ILLNESS O INJUY (elate Items 1, 2, 3 or 4 to Item 24E by Line) SEX 17. NAME OF EFEING POVIDE O OTHE SOUE 17a. 1. 3. 17b. NPI 8. PATIENT STATUS Single Married Other Full-Time Part-Time Employed Student Student 10. IS PATIENT S ONDITION ELATED TO: a. EMPLOYMENT? (urrent or Previous) b. AUTO AIDENT? c. OTHE AIDENT? YES NO YES NO YES NO 10d. ESEVED FO LOAL USE PLAE (State) ITY STATE ZIP ODE TELEPHONE (Include Area ode) 11. INSUED S POLIY GOUP O FEA NUMBE a. INSUED S DATE OF BITH MM DD YY b. EMPLOYE S NAME O SHOOL NAME d. IS THEE ANOTHE HEALTH BENEFIT PLAN? YES NO SEX If yes, return to and complete item 9 a-d. 13. INSUED S O AUTHOIZED PESON S SIGNATUE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. SIGNED 16. DATES PATIENT UNABLE TO WOK IN UENT OUPATION MM DD YY MM DD YY FOM TO 18. HOSPITALIZATION DATES ELATED TO UENT SEVIES MM DD YY MM DD YY FOM TO 20. OUTSIDE LAB? $ HAGES YES NO 22. MEDIAID ESUBMISSION ODE OIGINAL EF. NO. 23. PIO AUTHOIZATION NUMBE ( ) c. INSUANE PLAN NAME O POGAM NAME M F PATIENT AND INSUED INFOMATION 1 2 3 4 5 6 2. 4. 24. A. DATE(S) OF SEVIE B.. D. POEDUES, SEVIES, O SUPPLIES E. From To PLAE OF (Explain Unusual ircumstances) DIAGNOSIS MM DD YY MM DD YY SEVIE EMG PT/HPS MODIFIE POINTE 25. FEDEAL TAX I.D. NUMBE SSN EIN 26. PATIENT S AOUNT NO. 27. AEPT ASSIGNMENT? (For govt. claims, see back) 31. SIGNATUE OF PHYSIIAN O SUPPLIE INLUDING DEGEES O EDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) YES NO F. G. H. I. J. DAYS EPSDT O Family ID. ENDEING $ HAGES UNITS Plan QUAL. POVIDE ID. # NPI 28. TOTAL HAGE 29. AMOUNT PAID 30. BALANE DUE $ $ $ 32. SEVIE FAILITY LOATION INFOMATION 33. BILLING POVIDE INFO & PH # NPI NPI NPI NPI NPI ( ) PHYSIIAN O SUPPLIE INFOMATION NPI a. b. a. b. SIGNED DATE NU Instruction Manual available at: www.nucc.org APPOVED OMB-0938-0999 FOM MS-1500 (08-05) NPI Exhibits MS 1500 Form 47

HNS Fax Inquiry Form HNS FAX INQUIY FOM POVIDE S INFOMATION HNS TO OMPLETE Today s Date: Date eceived by HNS: Provider s Name: Dr. Date esponse Sent: Fax: esponse Prepared By: Phone: Fax Number: (877) 329-2620 Number of Pages: Number of Pages: ontact Person: HNS Provider ep: Should claims for the attached member ID card be filed to HNS? What information from the attached member ID card should be in boxes 11, 11b, & 11c? hange of Practice Information please fax a Practice hange Form to our office. The patient and date of service circled on the attached EOB (and remittance statement) isn t a patient at this office. Please adjust accordingly. Please check the status of the following primary claim(s). Has HNS received the claim(s)? Please check the status of the following secondary claim(s). Has HNS received the claim(s)? Name: Name: ID #: ID #: Ins Plan: Ins Plan: Date of Birth: Date of Birth: Date(s) of Service: Date(s) of Service: Additional omments or Questions: Visit our website at http://www.healthnetworksolutions.net This message is intended only for the use of the individual or entity to which it is addressed. This communication may contain individual protected health information ( PHI ) that is subject to protection under state and federal laws, or other privileged, confidential or proprietary information of Health Network Solutions, Inc., that may not be disclosed. If you are not the intended recipient, or the employee or agent responsible for delivering this communication to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by replying to this fax and shred it once fax confirms. Thank you. 48 Select Health laims Filing Manual www.selecthealthofsc.com

Institute for Health and ecovery Integrated (IH) Screening Tool (SBIT) INSTITUTE FO HEALTH AND EOVEY - INTEGATED SEENING TOOL *Fax the OMPLETED form to the patient s plan with the requested information Absolute Total are Bluehoice HealthPlan arolina Medical Homes First hoice by Select Health Fax: 877-285-3226 Fax: 877-798-1028 Fax: 803-509-5366 Fax: 866-533-5493 Palmetto Physician onnections S Solutions UnitedHealthcare ommunity Plan SDHHS (Fee-for-Service) Fax: 888-781-4316 Fax: 866-907-4842 Fax: 866-456-6722 Fax: 803-255-8232 Women s health can be affected by emotional problems, alcohol, tobacco, other drug use, and domestic violence. Women s health is also affected when those same problems are present in people close to us. By alcohol, we mean beer, wine, wine coolers, or liquor. Parents Did any of your parents have a problem with alcohol or other drug use? Peers Do any of your friends have a problem with alcohol or other drug use? Partner Does your partner have a problem with alcohol or other drug use? Violence Are you feeling at all unsafe in any way in your relationship with your current partner? Emotional Health Over the last few weeks, has worry, anxiety, depression, or sadness made it difficult for you to do your work, get along with people, or take care of things at home? Past In the past, have you had difficulties in your life due to alcohol or other drugs, including prescription medications? Present In the past month, have you drunk any alcohol or used other drugs? 1. How many days per month do you drink? 2. How many drinkson any given day? 3. How often did you have 4 or more drinks per day in the last month? Smoking Have you smoked any cigarettes in the past three months? YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO Advice for Brief Intervention eview isk eview Domestic Violence esources eview Substance Use, Set Healthy Goals onsider Mental Evaluation Did you State your medical concern? Did you Advise to abstain or reduce use? Did you heck patient s reaction? Did you efer for further assessment? Patient eferred to: heck applicable box(es) Y N N/A Non-Pregnant 7 drinks/week 3 drinks/day At-isk Drinking DHE Quit Line DMH DAODAS Private Provider (Name & NPI) Pregnant/ Planning Pregnancy Any Use is isky Drinking Date Screened: Patient efused eferral: eferral Not Warranted: Medicaid ecipient #: Practice Name: Screening Provider s Name: Patient shealthplan: Practice NPI: For the best health of mothers and babies, we strongly recommend that pregnant women, or those planning to become pregnant, do not use alcohol, illegal drugs or tobacco. Safe levels of usage have not been determined. Language: ace: Ethnicity: Exhibits Institute for Health and ecovery Integrated (IH) Screening Tool (SBIT) 49

Prenatal isk Assessment Form Pregnancy isk Assessment Information Please fax this form to Select Health of South arolina at 1.866.533.5493. If you have questions, please call Bright Start at 1.888.559.1010. Provider Information Provider Name Tax ID # Address Phone Fax Member Information Member Name Medicaid ID # Address Date of Birth Language preferred Phone Tobacco Use Pre-Pregnancy 1st Trimester 2nd Trimester 3rd Trimester Average number of cigarettes smoked per day. If none enter 0; 1 pack = 20 cigarettes Pregnancy Information & History Date of first prenatal visit 17P andidate Yes No ED Gest. Age Gravida Para Pre-term Living Abortions: Spontaneous: Induced: Three consecutive abortions Last Pregnancy Low birth weight < 2500 grams History of incompetent cervix Fetal death greater than 20 weeks STD history Gestational diabetes Premature OM Pre-eclampsia/Eclampsia Postpartum depression Pre-term delivery (gest. age: ) lassical incision previous -section IUG Hx of DVT/PE ongenital anomaly: Other (specify) urrent Pregnancy Multiple gestation: Twins Triplets Other: Pre-eclampsia Eclampsia Premature labor Diabetes H sensitization enal disease Placenta previa Heart disease Sickle cell disease Abnormal ultrasound Premature rupture of membranes Hypertension Incompetent cervix Alcohol or drug problems STD (sexually transmitted disease) Previous delivery within 1 year of ED Late and/or inconsistent prenatal care Poor weight gain IUG 2nd/3rd trimester bleeding Periodontal disease PIH Seizure disorder Asthma HIV No current risk Other (specify) Active Mental Health onditions No mental health conditions Schizophrenia Bipolar Depression Other (specify) Social, Economic and Lifestyle Issues No identified social, economic or lifestyle issues Eating disorder Intellectual impairment Homelessness Opiod therapy Substance abuse (specify type) Mental/physical/sexual abuse (current or hx. of) Please call Bright Start or fax an updated form if the member has any changes in condition during pregnancy. This updated information can assist Bright Start with member outreach. Maternity Authorization # overing dates of service to Select Health Bright Start PO Box 40849 harleston, S 29423 Toll free: 1.888.559.1010 Fax: 1.866.533.5493 www.selecthealthofsc.com 50 Select Health laims Filing Manual www.selecthealthofsc.com

UB-04 Form 1 2 3a PAT. NTL # 4 TYPE OF BILL b. MED. E. # 5 FED. TAX NO. 6 STATEMENT OVES PEIOD 7 FOM THOUGH 8 PATIENT NAME a 9 PATIENT ADDESS a b 10 BITHDATE 11 SEX b c d ADMISSION ONDITION ODES 12 DATE 13 H 14 TYPE 15 S 16 DH 17 STAT 18 19 20 21 22 23 24 25 26 27 28 29 ADT 30 STATE e 31 OUENE 32 OUENE 33 OUENE 34 OUENE 35 OUENE SPAN 36 OUENE SPAN 37 ODE DATE ODE DATE ODE DATE ODE DATE ODE FOM THOUGH ODE FOM THOUGH a a b b 38 39 VALUE ODES 40 VALUE ODES 41 VALUE ODES ODE AMOUNT ODE AMOUNT ODE AMOUNT a b c d 42 EV. D. 43 DESIPTION 44 HPS / ATE / HIPPS ODE 45 SEV. DATE 46 SEV. UNITS 47 TOTAL HAGES 48 NON-OVEED HAGES 49 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 11 11 12 12 13 13 14 14 15 15 16 16 17 17 18 18 19 19 20 20 21 21 22 22 23 50 PAYE NAME PAGE OF 51 HEALTH PLAN ID EATION DATE TOTALS 52 EL. 53 ASG. 54 PIO PAYMENTS 55 EST. AMOUNT DUE 56 NPI INFO BEN. 23 A 57 A B OTHE B PV ID 58 INSUED S NAME 59 P.EL 60 INSUED S UNIQUE ID 61 GOUP NAME 62 INSUANE GOUP NO. A A B B 63 TEATMENT AUTHOIZATION ODES 64 DOUMENT ONTOL NUMBE 65 EMPLOYE NAME A A B B 66 DX 67 A B D E F G H I J K L M N O P Q 69 ADMIT 70 PATIENT 71 PPS 72 73 DX EASON DX a b c ODE EI a b c 74 PINIPAL POEDUE a. OTHE POEDUE b. OTHE POEDUE 75 ODE DATE ODE DATE ODE DATE 76 ATTENDING NPI QUAL LAST FIST c. OTHE POEDUE d. OTHE POEDUE e. OTHE POEDUE ODE DATE ODE DATE ODE DATE 77 OPEATING LAST NPI QUAL FIST 80 EMAKS 81 a 78 OTHE NPI QUAL b LAST FIST 68 c 79 OTHE NPI QUAL UB-04 MS-1450 APPOVED OMB NO. 0938-0997 d LAST FIST THE ETIFIATIONS ON THE EVESE APPLY TO THIS BILL AND AE MADE A PAT HEEOF. National Uniform NUB Billing ommittee Exhibits UB-04 Form 51

Universal 17-P Authorization Form 17-P UNIVESAL AUTHOIZATION FOM MO Prior Authorization equests: Fax the completed form to the patient s MO. Absolute Total are Bluehoice HealthPlan First hoice by Select Health Unison Health Plan P: 803-933-3689 P: 866-902-1689 P: 888-559-1010 x55251 P: 877-651-2217 F: 866-918-4451 F: 800-823-5520 F: 866-533-5493 F: 866-639-7785 Provider Information: Provider Name (Please Print) Address ity/state/zip Phone Fax Subspecialty MFM/Perinatology Other: Tax ID Patient/Member Information: NPI Patient/Member Name Medicaid ID (Please Print) Member Plan ID DOB Phone Number Address ity/state/zip Pregnancy Information & History: G T P A L (Note: A=abortions both spontaneous & medically induced) ED Bed est Yes No Experiencing Preterm Labor Yes No Major Fetal or Uterine Anomaly Yes No (Home administration available if on bed rest.) Singleton Pregnancy Multiple Pregnancy At least 16 weeks gestation Yes No Previous spontaneous singleton preterm birth between 20 36 weeks Yes No Medication Allergies: No known drug allergies Other Pertinent linical Information: 17-P riteria & Pharmacy Information: Women eligible for 17-P must meet the following criteria: History of previous spontaneous singleton preterm birth between 20 and 36 weeks At least 16 weeks gestation at initiation of therapy No major fetal or uterine anomaly Pharmacy: Ship to patient s home address End Date of Service Ship to provider s address End Date of Service Shipping Preference: egular Mail Ground Overnight Ordering Physician s Signature: MO Use Only: Approved Denied 17-P Authorization # Dates of Service: Number of Injections: Please note that our review applies only to the authorization of medical necessity and benefit coverage. This authorization is not a guarantee of payment unless the member is eligible at the time the services are rendered. 4.2010 52 Select Health laims Filing Manual www.selecthealthofsc.com